Introduction: Modern warfare, with the use of long-range, high-impact weaponry, has escalated both the number and severity of injuries compared to past conflicts. Additionally, widespread infrastructure destruction, particularly of roads, complicates medical evacuation. Alarmingly, healthcare faces continuous targeted attacks, as verified in Ukraine, indicating a disregard for the Geneva Convention and humanitarian law. All of this combined has resulted in increased morbidity and mortality. To improve safety and efficacy in future medical evacuations (MEDEVAC), it is desirable to examine current emergency medical services (EMS) operations in modern warfare. This study aims to describe challenges faced by ambulance personnel operating in Ukrainian war zones during the evacuation of casualties and to understand the strategies employed to mitigate risks. Methods: The study uses two data sources: a literature search through academic databases, grey literature, and websites with relevant keywords, and interviews with personnel (n = 11) experienced in Ukraine EMS and war zones. The data were thematically analyzed. Results: Literature descriptions of EMS being targeted for attacks were supported by study participants’ first-hand testimonies. Participants described a constant fear of being attacked while evacuating casualties, as well as adjustments in work methods to enhance safety, such as keeping the vehicle in motion or hidden, and modifying its colors (camouflage), lighting, and interiors to reduce the risk of being targeted. Conclusion: It may not be obvious to civilian EMS that some protective measures taken when operating in a context of warfare may breach their non-combatant protection under international humanitarian law, in effect rendering them a form of military combatant status, while lacking in military protection and training. This ethical and judicial grey zone dilemma must be addressed by civilian and military actors, while acknowledging that its root cause is unlawful and condemnable military attacks on healthcare services.
Gyllencreutz et al. (2026) studied this question.