Medical Wargames: Preparing for Success in High-Intensity Conflict

By Colonel Max Talbot, MSM, CD, Lieutenant-Colonel Edith Arbour, CD, Captain Jon Jeffrey, CD, Major Gabriel Painchaud, CD and David Redpath

In future conflicts, enemy fire and electronic warfare may threaten early access to transfusion and surgery by disrupting forward-deployed medical force elements and their lines of communication.^{Footnote 1}  In addition, deep strikes may create a non-linear battlefield where small medical teams need to be distributed widely to provide care to spatially dispersed casualties. Under such conditions, NATO’s doctrinal guidance to provide advanced care within one to two hours of wounding may be difficult to implement.^{Footnote 2}  Wargaming provides a flexible method to explore this problem.

The authors recently developed Lifeline Latvia, an unclassified link and node wargame designed to generate insights into the delivery of medical care to a battle group involved in a high-intensity engagement. The prototype game was played twice—with different scenarios—on consecutive days in March 2025. Subject matter experts commanded key nodes and engaged in open play. Combat was abstracted to allow a focus on medical activities. Enemy weapons’ effects were based on open-source information, which was judged sufficiently granular for a medical wargame.

Five key design decisions may provide inspiration for future medical wargames. First, one-hour game turns allowed physiology to unfold on a medically relevant timescale while maintaining playability. Second, unstable patients were assigned an hourly probability of mortality. For instance, a bleeding patient in severe shock may have been assigned a 40% probability of mortality per hour (per game turn) without treatment, which was adjudicated by a random card draw.^{Footnote 3}  Following blood transfusion and surgery, mortality sequentially decreased to zero based on the simplifying assumption that the post-operative died-of-wounds rate would be negligible over a short timescale. Therefore, the game controllers avoided subjective adjudication of mortality, which could have been a slow and subjective process. Third, the game captured the marginal benefit of positioning surgical teams further forward by including a realistic incidence of patients with noncompressible hemorrhage and simulating their deteriorating physiology.^{Footnote 4}  Noncompressible hemorrhage was an important component of the game, since one of the aims of forward-deployed surgical teams is to decrease preventable mortality from this injury pattern. Fourth, the duration of tourniquet application was documented. Prolonged tourniquet application causes local and systemic complications, which can be prevented with tourniquet reassessment protocols for medics and/or rapid transport to a surgical team.^{Footnote 5}  Therefore, the game also attempted to capture the reduction in limb ischemia achieved by positioning surgical teams closer to the point of injury. Finally, relatively minor injuries were excluded from the game to declutter the board and focus on patients whose outcome could be meaningfully improved by the medical system.^{Footnote 6}

These game features emphasized the trade-offs involved in positioning surgical teams in the battlespace. In principle, a surgical team can provide timely hemostasis and revascularization when positioned close to the point of injury. However, greater exposure to enemy fire, unreliable supply lines, and inferior operating conditions may limit the team’s effectiveness or even threaten its survival.^{Footnote 7}  Therefore, surgeon proximity to the point of injury may be limited by the prevailing tactical conditions. In addition, surgical teams have reduced mobility once they receive patients, which makes their location at the start of an engagement even more critical. During the second game, these issues became apparent. For example, a forward-deployed team accumulated a queue of casualties requiring surgery, had difficulty obtaining outbound patient transport, and ultimately sustained a direct kinetic strike. As intended, the game provided a platform to explore the challenge of surgical team positioning.

Notably, the game provoked discussions about the tactics required to enable small surgical teams to function in the red zone. Advanced tactics that deserve consideration include deception, fortifications, signature reduction, multispectral camouflage, and uncrewed aerial system countermeasures.^{Footnote 8}  The adoption of advanced tactics by medical units will require close collaboration between the Canadian Army and the Canadian Forces Health Services Group.^{Footnote 9}  Due to rapidly evolving enemy technology and tactics, a permanent solution is not attainable. Wargames, realistic exercises, deployed experience, and aggressive innovation will be continually required to maintain a competitive advantage.

The game also generated important observations about ambulances, blood product logistics, critical care transport, and command and control. As in many wargames, specific outcomes had limited generalizability as they were highly dependent on player decisions and stochastic events. However, some of the game’s compelling trends will inform future exercises, modelling, and operations research.

Beyond tactical insights, the game created significant value by providing a stage for professional conversations. The game’s fast pace required direct non-hierarchical discussions, which created a favourable learning environment and fostered collaboration. Players cooperated to evacuate and treat mounting casualties, often by adopting creative non-doctrinal measures. In addition, many participants gained a better appreciation for the perspectives of members in other occupations or units. The authors believe that wargaming should be adopted more widely in military medicine because of its broad applications for team building and professional development.

The authors specifically encourage further development of medical wargames focused on the Baltic theatre. Future games could improve game mechanics, expand to larger formations, and include allied medical assets. Increased participation by Canadian Army and Latvian personnel would also improve the game’s fidelity and accelerate the integration of medical force elements into the Multinational Brigade-Latvia.

About the authors

Colonel Max Talbot is a Regular Force orthopaedic surgeon embedded at McGill University Health Centre.

Lieutenant-Colonel Edith Arbour is a Health Services Management Officer and the Senior Staff Officer for Personnel Generation at Canadian Forces Health Services Headquarters.

Major Gabriel Painchaud is a Health Services Management Officer and a student on Joint Command Staff Programme 52. Major Painchaud led the development of the Latvia Multinational Medical Unit between 2022 and 2024.

David Redpath and Jon Jeffrey are experienced game designers and analysts in the Joint Wargaming Section of the Canadian Joint Warfare Centre. Captain Jeffrey is also a Battery Commander with 30 Field Artillery Regiment.

The authors sincerely appreciate the invaluable support provided by the Directorate of Health Services Operations throughout this project.

This article first appeared online in the Short Bursts section of the Canadian Army Journal (October 2025).