The first ISAF Medical Lessons Learned Workshop – The First Steps Towards a Robust NATO Medical Lessons Learned System


The first ISAF Medical Lessons Learned workshop was held on 20–22 October 2014 in Budapest, Hungary. Organized and presented by the Lessons Learned Branch of the NATO Centre of Excellence for Military Medicine (MILMED COE), the workshop was a remarkable success.

Participants from 17 NATO and Partner Nations (AUS, BEL, CAN, CZE, DNK, FRA, DEU, HUN, ITA, LTU, NLD, NOR, ROU, SWE, CHE, GBR, USA) spent 3 days exploring information that was organized by the staff of the Lessons Learned Branch of the MILMED COE. Supported by COMEDS and the COE’s Steering Nations the workshop was aligned with NATO guidance and long term Transformation objectives. The goals of the gathering were to share some of the successes of LL within ISAF medical, to examine the various observations, lessons, documents, and briefings that the team was able to discover, to recommend areas to prioritize for further work or dissemination of lessons and to build a network of Medical LL POCs across NATO. “We sent two teams to what we felt were the ISAF information nodes to dig into the electronic systems to see what was available,” stated Branch Chief Chris WESTBROOK CAPT (N), USA. “While there are many documents with observations and lessons, there are very few documents actually labeled as lessons for NATO. Instead, many coalition Nations collect and process ­lessons at the national level but those are not available for the coalition. It is important that we start sharing this information across NATO; that is our desire – to build a system of respect and trust where improvements can be shared for the benefit of the entire organization.” In addition to the documents collected from ISAF, Canada, Czech Republic, Denmark, Germany, Great Britain, Hungary, The Netherlands, Romania and The US provided national inputs.

During the first day of the meeting, the participants received multiple presentations, ranging from a strategic to an operational view point, demonstrating some of the lessons that have been learned over the 13 years of ISAF.

The second day was spent doing Syndicate work. Each Syndicate was chaired by an expert within that area discussed with many having served as the Medical Advisor for ISAF or Chairman of a COMEDS Working Group or Panel. The participants were divided into 6 groups which reviewed the documents that the team collected. LTC Tamás BOGNÁR, (HUN), Lessons Analysis and Deputy Branch Chief remarked “We processed the documents we discovered into more than 250 individual worksheets for the syndicates to review.” The LL team determined which documents matched to the different syndicates. All 250 + works sheets were available to all syndicates and were cross referenced by key word, title and generating nation, among other indicators. “All of these documents are available online on the MILMED COE portal [] and anyone who would like to review them for additional lessons can request access by selecting “Medical LLDB” under the Library tab.”

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During the third day the Syndicates discussed issues within their topic, putting the different pieces of the puzzle together, organizing the observations. The final product was a list of issues that the syndicate members believed were important, their evaluation of the priority of the issue, and recommendations moving ahead.

“It was a fantastic meeting and demonstrated that the NATO Military Medical Centre of Excellence is leaning forward and is positioned to create a functioning Medical Lessons Learned process,” stated one of the attendees.

Previously, the NATO Joint Analysis of Lessons Learned Centre in Lisbon, Portugal (JALLC) had a medical staff member. That position was removed about 18 months ago and with the loss of that expertise the Centre necessarily had to decrease their focus on Medical issues. Additionally, the Joint Centre is primarily an Analysis Centre and the collection and organization of the observations is not part of their responsibilities.

Tab 3 KopieBy positioning itself as the coordinator and collector of observations and lessons, the Lessons Learned Branch of the MILMED COE can add value to the system, processing and sharing Lessons and Best Practices for all members of the Coalition. “We are building a roadmap to the future of the delivery of Health Support Services. The members of the alliance have delivered amazing health care, and we need to collect and share the Best Practices across the organization to ensure that everything that has been learned can continue to save lives, money and resources.”

Main Meeting Products:

  1. A summary of the highest priority, most urgent targets for improvement as determined by a review of the available documents
  2. A Network of Centres and staff interested in improving NATO medical Lessons Learned processes
  3. Discussion and exploration of ways to adapt and improve medical LL within NATO

All of the observations, source documents, presentations and attendee list are located on the MILMED COE LLDB portal at

Medical Command and Control Syndicate

Chaired by Brigadier General Martin BRICKNELL (GBR), former ISAF Medical Advisor with multiple experiences in ISAF missions, the group extracted 5 main lessons. The most critical and time sensitive among the 5 lessons concern the Medical Informatics Systems and Standard Operating Procedures (SOPs) for the Patient Evacuation Coordination Cell (PECC). Beginning in 2003, NATO has been sponsoring the development of a comprehensive IT solution for medical support services and documentation. This suite of programmes, MEDICS, is a portion of the much larger Logistics package (LOGFS). Due to complex issues with the contract for LOGFS, the MEDICS programme release has been delayed. It was the opinion of the Syndicate that the functional parts of MEDICS should be released now. As the contracting issue is resolved for the overall programme, the released (and therefore tested) components could be returned to the larger programme, providing a base for further development.

The second topic identified as critical and time sensitive is the development of a concept document for the PECC. Over the last 13 years of ISAF an unprecedentedly successful MEDEVAC process has been driven in part by Best Practices within the Patient Evacuation Coordination Center. It was the feeling of the Syndicate that the lessons learned for the PECC need to be captured now, before the knowledge is lost. Specifically, ACO should sponsor the creation of an expert panel to produce a NATO SOP for PECC operations.

The three other findings from the Syndicate focus on the upcoming AJP 4-10 update. The Allied Joint Medical Support Doctrine (AJP 4-10) (currently in update) is the over-arching doctrine for medical support within NATO. The Syndicate recorded three comments to guide further Medical Service development. The first is that the refinements in the Logistics chapters of the AJP 4-10 are adequate to address many of the medical logistics issues described in the observations and that alliance nations should be compelled to implement the requirements within the doctrine. The second recommendation is that ACO needs to sponsor the development of a Joint Medical Division SOP within the multinational headquarters, specifically to outline the roles and responsibilities of the Medical Advisors (MEDAD) and to codify the policies and procedures across that level of the alliance. The final comment noted that the Information System requirements for medical services are outlined within the AJP 4-10 B (soon to be released) and as mentioned above, the member nations need to ensure that the requirements included in the document, which has been approved by all alliance member nations, are followed and supported.

Prehospital Care and MEDEVAC Syndicate

Based on the previously shared UK and US lessons learned studies and the ISAF worksheets, the Syndicate, chaired by ACO Medical Advisor Brigadier General István KOPCSÓ (HUN), identified multiple issues for further discussion. The first finding addresses prehospital standard of care. It was discussed that not all NATO member nations have a standard for Point of Injury (POI) care, which results in variance in care delivered and different, non-harmonized standards. For instance, different analgesic medicine and equipment are in use by the nations. This can result in over or under treatment by subsequent medical personnel. The Syndicate recommended the use of the concepts within the Tactical Combat Casualty Care (TNCC) to develop a POI care standard. By implementing a standard, the variation can be reduced and an approved training curriculum and skill assessment can be developed. This would also answer another observation by the Syndicate that a Prehospital care Performance Improvement (PI) initiative is lacking from NATO. To ensure that Prehospital care achieves the same exceptional standards that hospital care has achieved, a formal Prehospital PI system needs to be developed and implemented.

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Another topic discussed by the Syndicate was the Field Medical Card (FMC). Observations indicated that the form is rarely used and when it is, the information is not accurate, updated or helpful. This, along with the observations that the process for documentation of Prehospital care is inadequate, generated the recommendation that ACO should direct an initiative to improve Prehospital care documentation. Additional factors that might have negative influence to the POI care are the lack up-to-date military and medical skills of the medical providers and first responders. The Syndicate recommended seeking opportunities for pre-deployment training which may include training at civilian centers and Command wide participation in training as a multinational team prior to deployment. In addition to medical training and learning to operate as a unit despite having the team formed from multiple nations, medical personnel need improved military skills training however it is critical that alliance guidelines be developed to codify the complex interaction between non-combatant personnel according to the Geneva Conventions and the need and right for self-protection and protection of patients under their care.

The next key topics that the Syndicate discussed were medical evacuations during operations, timelines and future mission planning. Concerning MEDEVAC timelines, the experts stated that the 10-1-2 Rule still applies within NATO, however that a scientific, data-driven review is necessary to provide refinements to this doctrine. The Syndicate concluded their discussion on MEDEVAC issues by noting that during ISAF, the alliance eventually achieved near complete air dominance and had favorable time/distance considerations, and that future operations will probably not have these factors, especially in the early phases. Improvements in medical planning must include a focus on ground transportation and prolonged pre-hospital care and transport times having the right capabilities with the right mix of skills at the right location will be critical to the survival rate under conditions with longer transport times to a medical treatment facility.

Medical Treatment Facility Care Syndicate

The largest Syndicate was chaired by Colonel Alexander FAAS (SUI), the chairman of the COMEDS Healthcare Working Group. The team screened the worksheets and identified the 5 most important topics concerning care within Medical Treatment facilities. Numerous shared observations highlighted the importance of the multinational pre-deployment training such as the HOSPEX in UK or CACHIRMEX in France. These exercises train the designated health care personnel to successfully cope with the significantly different workload and spectrum of injury seen in deployed ROLE 2/3 compared to that seen in the daily practice in the home country and to develop an international team operating within a multinational environment. The Syndicate strongly recommended that medical personnel complete a pre-deployment and attend unit level, multinational training in advance of deployment, which was in complete agreement with the last recommendations by the Prehospital Care and MEDEVAC Syndicate.

In addition to the above recommendations, the Syndicate noted that high quality medical care requires that the leadership knows the individual staff members’ skill sets and that they must have a way to monitor and communicate information. Specifically, the Syndicate suggested that NATO describe more fully and define more clearly the required medical skill set for the various clinic positions and that a cross-alliance process for communicating credentialing information needs to be developed and codified in a STANAG.

Considering advances in clinical care, the control of non-compressible hemorrhage was identified as the most critical topic for future research into Combat Casualty Care. The Syndicate members also underlined the necessity for the development of new strategies for delivering blood products, medical devices, pharmaceuticals and surgical skills in the operational setting as well as researching new technologies that will make this possible.

The forth topic addressed concerned the delivery of Mental Health services. Multiple observations identified forward-deployed mental health care delivery as a force-multiplier and that mental health issues are common complaints that present at all echelons of care. Identifying and managing acute stress is very time-intensive and requires specially trained clinical staff, and bringing mental health capability further forward might be the solution, the Syndicate recommended investigating how to deliver forward mental health capability.

The final topic presented by the Syndicate addressed shortcomings in the Lessons Learned process itself. They noted that the majority of lessons came from just a few sources. The experts recommended reviewing the current process and developing a new, more inclusive process not only for collecting observations but also critically important is the sharing of the information gleaned from the input.

Medical Training Syndicate

The Syndicate, chaired by Lieutenant Colonel Rob MEIJERING (NLD), former secretary of the COMEDS Military Medical Working Group, analyzed the collected medical training related lessons. The Syndicate specifically reviewed observations concerning the provision of medical training to host nation personnel and did not address training provided to deploying alliance troops. The central recommendation is the establishment of a single medical training authority to synchronize training across an operation. This would include providing a mechanism for promulgating the training developed by the Host Nation, processes for ensuring competency of graduates, and a more transparent and optimized NATO training structure despite the actual, often confusing situation. The Syndicate members discussed the advantages and drawbacks of outsourcing the training to contactors. While some strengths were noted, the Syndicate focused on areas of concern. It was noted that there is a high variance in the skills and knowledge of contracted trainers and that the used training materials were not standardized and the quality was inconsistent. The members agreed that NATO training authorities must provide mission specific standards and mechanisms to monitor achievement of those standards by contacted trainers.

Observations noted that contractors can expand the often limited pool of military trainers but restrictions based on the operational environment or simple refusal of individuals to accept the risk of travel to a training location often disrupted the trust relationship that is key to the success of the process.

The next discussed topic was the mentoring and advisory programme, which has become more of a focus as NATO transitions from the ISAF mission. The Syndicate commented that mentoring requires a specific set of knowledge and skills, paired with the appropriate mindset, and that the mentor relationship must be allowed to develop over an appropriate time frame. Because of these facts, careful selection of mentors, advisors with cultural awareness, innate mentorship ability and interpersonal communication skills is required. Previous experience and exposure in a training environment can also be highly beneficial and contribute to mentorship success. Additionally, for relationship building and trust development, longer tours for mentors and advisors are beneficial however the duration of those deployments need to be balanced with skill maintenance and retention for the mentor and that the nature of skills, the profession involved and personnel availability all impact those decisions. It was noted that a one-size-fits-all tour length is counterproductive and for medical specialties of “high value and low density,” repeated, shorter deployments may be appropriate. Because the learning of clinical skills is dependent on the patient population, it is critical that the timing of deployments for those teaching and mentoring on the care of combat injuries be structured to match the “fighting season.”

The last topic addressed, encompassed the whole spectrum of military and medical competencies of multinational medical staff. In line with the statement of Syndicate 4, the lack of experience working in a multinational medical setting and the inconsistency between personal skills and position requirement are a living problem in the deployed multinational medical units. This fact underscores the need of a well-structured and mission tailored medical pre-deployment training. To provide enhanced survivability for wounded soldiers, NATO has begun to bring specialized medical capabilities as forward as possible (in high risk, austere environments). To support this trend, the pre-deployment training of medical staff must cover military (warrior) skills in addition to the enhanced clinical competencies.

Finally, the Syndicate identified the risk of the declining emphasis on the Force Health Protection Measures during an operation. Specifically, as a mission progresses, the Commander’s focus on measures to monitor and protect the health of the fighting force tend to diminish, a thought process develops that if people are staying healthy then you must not need the system. As is well known within the medical community, relaxing FHP measures often results in the resurgence of preventable illnesses and injuries. It was therefore recommended that continuous, innovative training emphasizing the importance of the FHP measures be developed and provided to Key Leaders at all command levels. The final finding was addressed to planners, both medical and non-medical, since the new definitions of role-capabilities don’t seem to be universally understood, these definitions need to be embedded in planning curricula. Updating the non-medical planning courses is also recommended.

Medical Lessons Learned / Lessons Identified Syndicate

Brigadier General Stefan KOWITZ (DEU), former ISAF and NATO Joint Forces Command Medical Advisor in Brunssum, was the chairman for the Syndicate examining the Lessons Learned / Lessons Identified Process (LLP) itself. Worksheets concerning this topic were not only generated by those deployed to the ISAF mission but were also submitted by the teams from the COE who prepared the conference materials. It was felt that the LLP, as it functions now, has not been able to inform NATO policy as robustly as it should be able to. An overview of the LLP uncovered the following major points, some nations have successful LL processes and those should be mined for Best (Good) Practices. Overall the NATO process operates in parallel with national processes and therefore there is little sharing of observations between nations. This is often confounded by the fact that the observations and lessons are recorded on a classified system, not because of the information contained within the submission but because that is the location of the process. This severely limits the utility of observations and nearly eliminates the chance of sharing across the alliance. It was also determined by the Syndicate that making adjustments to this should be a priority for NATO. Another primary conclusion of the Syndicate is that there is a loss of trust in the LLP and that a rebranding would help reinvigorate a renewed focus. By modifying the overall concept; improving the feedback to the person submitting the observation the trust in the system could be increased, and therefore improve the quantity and quality of submissions. Also, by educating the rank-and-file on the LLP to include the live saving changes that have been implemented from the LLP, an organizational change can be fostered where observation submission becomes standard.

In addition to these comments it was also noted that the Medical portion of the LLP in NATO is “hidden” within the J4 structure and that while some countries have very robust LLPs, the observations and lessons become stove-piped and are not shared across the alliance. Finally, while there are organizations within NATO that deal with the overall LLP, they do not have medical personnel. Because of the special requirements and language within Medical, it is critical that LLP for medical be managed by medically trained staff. Also, understandably, medical tends to have a lower priority across the warfighter community and gets less attention than other military-skill specific sections.

The last major point discussed by the Syndicate addressed the larger field of Knowledge Management (KM). After much discussion, it was agreed that Lessons Learned is just one part of the broader KM concept which includes, among other items, mechanisms for creating Communities Of Interest (COIs), resource catalogues, communication tools and Subject Matter Expert (SME) rosters in addition to Lessons Learned.

The recommendations from the Syndicate are that an organization within the NATO Medical community should become the lead for NATO Medical Knowledge Management and that the MILMED COE is well positioned to assume that role. The LLP needs to be reviewed and organized along lines that encourage input in a manner that generate trust within the system. Also, the KM system needs to be developed so that it is easy to use and presents the information in an unclassified manner, allowing for the site to be located on the standard internet. Lastly, in order to collect the valuable information in theatre before it is lost as the current mission ends, visits to NATO mission sites and exercises need to be supported.

Civilian Military Interface Syndicate

Brigadier General Norvell COOTS (USA), former Medical Advisor of ISAF Joint Command, chaired this Syndicate. The ISAF Mission was completed at the end of 2014, but training, advice and assistance for the Afghan Security Forces and institutions will continue in the mission Resolute Support. Therefore the main emphasis will be on the mentoring and advisory programmes. In line with the findings of the Training Syndicate, it is important to understand that mentoring is more intensive than simply teaching and training. The experts emphasized the importance of a sophisticated, mission tailored pre-deployment mentor training. During this phase of the operations, civilian organizations (HN, IOs and NGOs for example) are going to take an increasingly central role. Each of these partners has their own culture, and understanding and harmonizing the different points of view is critical to success. NATO needs to develop training for deploying staff that addresses working with NGOs, IOs and Host Nation organizations. Many civilian organizations have developed training to teach their members how to work with the military. These trainings should be reviewed and the best portions modified as reciprocal processes. The experts – in perfect harmony with the findings of medical training Syndicate – also agreed that the key factors to building trust and successful mentoring are cultural awareness and understanding and good interpersonal communication skills. The Canadian Armed Forces have developed a robust mentor training programme which might be used as a template for the development of a NATO mentor training programme.

In addition to the mentoring issues mentioned above, two issues concerning civilian care were listed as critical. The first concerns the training of deploying NATO troops. Regardless of the “rules,” civilian casualties will present to mission medical staff. Currently the response to those patients is inconsistent and unclear. Various NATO nations have different policies which, during multinational operations, place the medical staff in an untenable situation. Additionally the ethics of medical decision making often requires one response while national rules dictate a different response. Furthermore, the issues surrounding the back transfer of patients from a coalition medical facility to a host nation facility, often a decrease in the level of care, has created moral and ethical conflicts for staff. It was recommended that ethics training be developed to assist medical staff and medical leadership in making these decisions and providing a base level of understanding concerning this discussion prior to deployment.

Finally, in future conflicts, NATO members will likely face asymmetric warfare including child-soldiers. It was determined as critical that ethical case scenarios and training be developed to help deployed members (both medical and non-medical) cope with these difficult situations.


We would like to thank the following Organizations and Nations who provided observations, time and expertise to make the workshop a success and help guide the way to further development of the Lessons Learned Process for Medical related issues within NATO.