When preparedness starts before the hospital

Between 2018 and 2019, some of our colleagues worked in non-government-controlled areas of Ukraine, delivering first aid training to school staff, local administration personnel, and older students (teenagers, mostly) on how to respond to the kinds of injuries a warzone produces. Blast wounds, firearm injuries, how to keep someone alive until medical help arrives. CPR on mannequins. Improvised wound care. The basics of keeping a person stable until a medic can reach them.

Some of those sessions took place in village schools within direct sight of the frontline. A classroom. A mannequin. And the conflict that made the training necessary was right on the other side of the river.

There was always someone from the army present. They never were intervening or instructing, just standing at the back of the room, watching. That detail, perhaps more than anything else, captured the reality of the environment in which the training was taking place. It was a reminder that what looked like a standard training session was, in fact, something else entirely.

This experience, repeated many times, left a lasting impression, not only of the resilience of the people being trained, but of something more operational: how much depends on what happens before a patient ever reaches a hospital.

In mass casualty events, the pre-hospital layer is often the difference between a patient who arrives with a chance and one who does not. The decisions made in the first minutes by bystanders, by school staff, by whoever happens to be present, shape everything that follows inside the hospital walls.

Health systems are often evaluated by what happens within their facilities. The capacity to absorb a sudden influx of casualties, however, is built far beyond those walls, in communities, in schools, and sometimes in places where the line between training and operational necessity is uncomfortably thin.

Preparedness does not start at the emergency department door.