Characterization of wound infections among patients injured during the Ruso-Ukrainian war in a Role 4 hospital

Dear Editor,

We have read with interest the article by Rodero-Roldán et al. entitled Characterisation of wound infections among patients injured during the Russian-Ukrainian war in a Role 4 hospital.¹ The title already includes a semantic inaccuracy with the use of the term “Role 4”, about which we would like to make several points. Although the article focuses on an interesting characterisation of microbial patterns in war wounds of Ukrainian combat casualties treated at the Hospital General de la Defensa “Orad y Gajías” military hospital, in their discussion the authors include a brief contribution about the concept of medical care in the military field.

“Apoyo Sanitario en Operaciones” [Medical Support in Operations] is defined as the set of activities, both in terms of planning and execution, aimed primarily at providing everything necessary for the prevention of illness in a timely manner, and the promotion, maintenance and restoration of health during the deployment, support and withdrawal of a military operation, with the aim of achieving the operational capability necessary for the successful completion of the mission. This is a facilitator that provides support to the Forces, helping to maintain combat capability and freedom of action.²

In this regard, the deployable component of medical support is organised in three echelons, parallel to the entity of the units of the Forces, in such a way that the first echelon is supported by the second and this in turn by the third. This allows for continuous and sustained medical assistance. This entire system is in turn supported by the fixed health centres that constitute the fourth echelon. A health echelon is understood to mean an organised set of human and material resources with a certain capability, which provides health support to an operational unit or organisation. While considering the term “echelon”, we must also consider the concept of “role”, which refers to functionality and describes the capability or level of care of a deployed healthcare facility. Four roles are described, with 1 denoting the least capability and 4 the greatest, each assuming the functions of the previous one.

According to the NATO (North Atlantic Treaty Organization) doctrine,³ Role 4 must cover the full spectrum of military healthcare, including definitive medical and surgical procedures, reconstructive surgery and rehabilitation. The aim of Role 4 is to provide definitive care to casualties strategically evacuated from the theatre of operations, either because the capabilities of the medical formations deployed in the area of operations are insufficient for the required treatment, or because the time expected for the recovery of the casualty exceeds that provided for by the evacuation standard agreed for the deployment.

In light of the above, we would like to conclude that, although Hospital General de la Defensa “Orad y Gajías” has the necessary human and material resources to qualify it for the fourth echelon of medical support as a deployment support medical centre with Role 2 capability,⁴ Hospital Central de la Defensa “Gómez Ulla” (Fig. 1) is the only Spanish military hospital with Role 4 capability,⁵ and which also has the necessary human and material resources to qualify as a fourth echelon facility within the medical support for military operations.⁴

Figure 1.

Hospital Central de la Defensa “Gómez Ulla”, 9 January 2021. Photograph by the authors.

Conflicts of interest

The authors declare that they have no conflicts of interest.