Tactical Combat Casualty Care Goes Viral: An Infodemiology Study of Military Medicine Public Interest During the Ukraine Conflict

Tactical Combat Casualty Care Goes Viral: An Infodemiology Study of Military Medicine Public Interest During the Ukraine Conflict | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report Tactical Combat Casualty Care Goes Viral: An Infodemiology Study of Military Medicine Public Interest During the Ukraine Conflict Sebastian Balda, Thomas Leone-Berry, Flavio Veintemilla-Burgos, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6794271/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background The Ukraine conflict has profoundly disrupted healthcare, with over 700 attacks on medical facilities reported since Russia’s 2022 invasion. This Infodemiological study analyzes wartime public health-seeking behavior through Google Trends data. Methods Using Tactical Combat Casualty Care (TCCC) guidelines, we categorized Ukrainian-territory searches (January 2020–January 2024) into treatment-related (Amputation, Tourniquet, Cardiopulmonary Resuscitation, TCCC) and etiology-related terms (Wounded in Combat, Hemorrhage, Deep Vein Thrombosis). Relative Search Volume (RSV) pre-invasion and post-invasion was statistically compared using Welch’s ANOVA (normally distributed data) or Wilcoxon signed-rank tests (non-normal distributions; SPSS v21.0). Results Analysis revealed a critical temporal disconnect: Etiology-related searches surged immediately post-invasion in 2022, evidenced by "Wounded in Combat" (RSV 7.4 to 54.5; p < 0.001) and "Hemorrhage" (RSV 61.2 to 67.8; p < 0.001), reflecting acute injury crises. In contrast, treatment-related terms peaked in 2023, aligning with allied TCCC training and searches in which TCCC interest rose dramatically (RSV 0.3 to 47.2; p < 0.001); Other searches increase as "Tourniquet" (RSV 12.8 to 38.3; p < 0.001) and "Cardiopulmonary Resuscitation" (RSV 0.2 to 28; p < 0.001). Moreover, "Deep Vein Thrombosis" queries declined (RSV 49.9 to 40.8; p = 0.017), suggesting a population-level shift from chronic to acute trauma priorities. Conclusions The delayed surge in treatment-related searches directly correlates with TCCC program implementation, demonstrating its capacity to shape population health responses during conflict. These findings support integrating TCCC into public health policy for future wars and highlight infodemiology’s utility in real-time crisis resource allocation. Tactical Combat Casualty Care Military Medicine Public Health Ukraine Russian invasion Infodemiology Figures Figure 1 Figure 2 Introduction The Ukraine war continues to have a serious impact on local people’s lives. Medical healthcare services have been severed, with more than 700 reported attacks on healthcare facilities since the start of the war. In 2022, there were 292 attacks on hospitals and clinics, 181 attacks on other health infrastructure, and 65 attacks on ambulances. There were also 86 attacks on healthcare workers, with 62 killed and 52 injured (1). The Office of the United Nations High Commissioner for Human Rights verified 10,582 deaths of civilians in Ukraine as of February 2024(2). While we cannot personally attest to whatever’s happening on a day-by-day basis in Ukraine's population, Google Trends (GTr) allows us to measure the level of interest on certain topics in specific locations and times. According to Eysenbach, Infodemiology is “the science of distribution and determinants of information in an electronic medium, specifically the Internet, or in a population, with the ultimate aim to inform public health and public policy”(3). Wartime medicine is a relevant aspect of healthcare in dire need due to the emergency in this population’s care. At times of war, complications such as hemorrhages persist as the main cause of death (4). According to this context, the study focused on Tactical Combat Casualty Care (TCCC) related topics and aims to analyze trends of Internet users’ interest health seeking patterns during a 21st century war plagued Ukraine using the Google Trends tool. Methods Study design: In this retrospective study, Tactical Combat Casualty Care (TCCC) EMS guidelines were used to select key terms related to Care Under Fire, Tactical Field Care, and Tactical Evacuation Care. the selected search topics were categorized as treatment and etiology accordingly. Treatment-related topics included: Amputation, Hospital, Dressing, Tourniquet, Military Hospital, Cardiopulmonary Resuscitation, and Tactical Combat Casualty Care. Etiology-related topics included: Deep Vein Thrombosis, Exsanguination, Hemorrhage, and Wounded in Combat. These topics were extracted from Google Trends as "topics," ensuring that search interest was captured across all relevant languages referring to the same concept. Data collection was limited to searches originating from Ukrainian territory between January 1, 2020, and January 1, 2024, covering the two years before and after the onset of the Russian invasion of Ukraine. Search volume was measured using Relative Search Volume (RSV). RSV data was downloaded and processed using SPSS (version 21.0). Pre-war and post-war RSV values were compared using Welch's one-way ANOVA for normally distributed data and the Wilcoxon signed-rank test for non-normally distributed data. Data System: GTr is a free public tool for analyzing searches on the Google search engine for specific topics and terms. It provides a categorized and anonymous database whose main metric is RSV. GTr has been used in health care studies from 2009 to 2013 and 34% of those studies were for surveillance. Among surveillance studies, 92% were validated against a reference standard data source, and 80% of studies using correlation had a correlation statistic (5). The datasets generated and/or analysed during the current study are available in the Google Trends repository, https://trends.google.es/trends/. Data collection/ processing Data on Gtr is collected continuously, and RSV results are reported daily. The data was downloaded from the GTr database on April 9, 2024. The period from which data was gathered is January 1, 2020, until January 1, 2024. This was made to analyze two years before and two years during the invasion. The main measure of interest was RSV, a normalized measure of interest over time. RSV is essentially a proportion of the search interest in a specific term relative to all Google searches during the specified period and geographic region. RSV value oscillates between 100 and 0 in descending order, reflecting the relative popularity of specific search terms within the selected timeframe and geographic scope (3). A higher value means a higher popularity. The data was downloaded as Comma-separated values (CSV) and statistical evaluations were processed using Statistical Package for Social Science (version 21.0; SPSS, Chicago, USA). Outcomes: This study includes, in detail, the growth and peaks of RSV on a scale from 0 to 100. Analysis: A mean RSV value was calculated considering values during the study timeframe as the Russian invasion of Ukraine occurred on the 21 of February 2022 values were classified before, and after this event as RSV Prewar average ,and RSV Postwar average. A Kolmogorov-Smirnov test was performed to assess the distribution, in which a p <0.05 was considered an abnormal distribution. For the normally distributed Welch's One-way ANOVA test was performed to analyze the difference in the search interest of the selected topics by comparing the search interest divided into pre warfare and post warfare groups a p <0.05 was considered statistically significant and an F value was obtained. For abnormally distributed variables, a Wilcoxon signed rank test was performed, considering statistically significant p<0.05. Results Public interest in treatment-related topics surged post-invasion, aligning with Tactical Combat Casualty Care (TCCC) principles. The results of the Kolmogorov Smirnov test showcase that hospital, and amputation were normally distributed while all the other variables were abnormally distributed. In Care Under Fire (immediate hemorrhage control), Tourniquet searches rose sharply (RSV 12.8 to 38.3;p < 0.001). Tactical Field Care drove spikes in Dressing (RSV 26.1 to 53.4; p < 0.001) and Cardiopulmonary Resuscitation (RSV 0.2 to 28; p < 0.001). Tactical Evacuation Care (advanced transport) saw increased searches for Hospital (RSV 62.4 to 72.3 ; p < 0.001) and Amputation (RSV 44.6 to 54; p < 0.001) Military Hospital (RSV 30.8 to 45.5; p < 0.001) . Overall, TCCC searches surged from (RSV 0.3 to 47.2; p < 0.001), peaking in 2023 alongside allied training efforts (Fig. 1). Searches mirrored acute combat injuries. Wounded in Combat skyrocketed (RSV 7.4 to 54.5; p < 0.001), while Hemorrhage (RSV 61.2 to 67.8; p < 0.001) and Exsanguination (RSV 32.6 to 40.2; p = 0.031) reflected bleeding-related urgency. Deep Vein Thrombosis declined (RSV 49.9 to 40.8; p = 0.017), overshadowed by trauma priorities(Fig. 2). Analysis of Figs. 1 and 2 reveals distinct search trends: trauma care strategies such as Amputation, Hospital, and Tactical Combat Casualty Care (TCCC) surged in 2023 a year after the conflict began coinciding with the phased rollout of allied-led TCCC training programs. These programs emphasized critical protocols: hemorrhage control (Care Under Fire), wound stabilization (Tactical Field Care), and transport logistics (Tactical Evacuation Care). In contrast, acute injury-related terms like Wounded in Combat, Hemorrhage, and Exsanguination spiked immediately in 2022 as the invasion escalated. An explanation for this temporal disconnect could be that while urgent injury-related queries rose at the war’s onset, treatment-focused searches increased later, driven by structured training dissemination despite immediate medical needs existing since 2022. Discussion War alters aspects of life and shifts people's priorities. Since healthcare accessibility has taken a heavy toll, people’s interest adapts to the current context ( 6 ).The war in Ukraine influences the interest in medical web searches. Such as, hospital and hemorrhage as they were the most searched topics in the study as medical facilities were attacked during war and bleeding became a major concern for the Ukrainian population. There was a notable increase in searches for treatment-related terms during wartime. In searches for treatment, “Amputation” and “Hospital” search interest rose the most, reflecting the heightened interest in these topics. However, we cannot assume the intent behind these searches. This may be a key factor for research studies, underscoring the need for studies and interventions that address both immediate concerns and underlying health issues for better public health outcomes. The changes in RSV on topics related to etiology from 2020 to 2024 in Ukraine as shown in Fig. 2, followed an interesting pattern when wounded in combat search peaked also did the other etiologies such as hemorrhage and exsanguination dramatically increasing after the Russian invasion of Ukraine began showcasing a change in search pattern and use of the internet for immediate medical needs in times of conflict. Heightened interest in bleeding related topics after the start of the war can also suggest the relevance of an organized emergency medical service in war plagued countries. To limit the number of deaths to crossfires, avoiding the loss of innocent people’s lives. One of the branches of emergency medical services is Tactical Combat Casualty Care (TCCC). Its primary objectives consist of providing early medical care to limit casualties during combat. Since its implementation, US military survival rates have reached historic heights. Ukraine, allied with the US, shows a growing interest in TCCC ( 4 ). As illustrated in Fig. 1, the TCCC influences the RSV of topics related to treatment from 2020 to 2024 in Ukraine. When searches on TCCC peaked in 2023 also the searches for hospital, cardiopulmonary resuscitation, amputation, and military hospital. Although the Russian invasion began in 2022, an explanation for this could be the direct influence of allied forces training the Ukrainian population on TCCC( 7 ), influencing the search pattern for other topics. TCCC is directed to the medical and nonmedical population to improve mortality rates on preventable deaths. This finding is a positive sign that training has a positive effect on the population's health education, and it could be a potentially beneficial policy for other wars in the future. War-related medical care has been a topic of interest even in times of peace. According to Gabor and Lauren, ever since the calamity of 9/11 medical journals have increased their interest in publishing disaster medicine articles ( 8 ). However, too little has been written about the shift in public interest regarding medicine in times of war. A study by Takahashi focuses on people's medical inquisitiveness via tweets regarding “mental health” ( 9 ). Management of cardiovascular injuries and complications during wartime is essential to reduce mortality and improve survival. Treatment strategies such as cardiopulmonary resuscitation, amputations, tourniquets, and related medical supplies, for instance, dressings have evolved dramatically through lessons learned from modern conflicts in wars, such as Iraq and Afghanistan. ( 10 ) Lack of hemorrhage control and immediate care are among the leading causes of death during armed conflict. ( 11 ) During the Global War on Terror, many lives were lost to exsanguination before medical care could be reached, highlighting the importance of prehospital treatment for hemorrhage control. One of the solutions implemented was the reintroduction and widespread training in the use of tourniquets which dramatically reduced deaths from exsanguination ( 12 ). The tourniquet is an intervention originally implemented by Jean-Louis Petit and was refined by centuries of military experience to form a core part of what is now known as Tactical Combat Casualty Care (TCCC)( 13 ). Therefore, the use of tourniquets combined with gauze and dressings is essential in wound management, becoming a fundamental pillar in medicine during war. ( 12 – 14 ) Cardiovascular stress and thromboembolic complications from immediate injuries contribute greatly to cardiovascular conditions that can severely impact the health outcomes of those affected( 15 ).There is a significant increase in the incidence of amputations during armed conflict, as evidenced in the war in Iraq and Afghanistan. Appropriate management of amputations is necessary to prevent immediate and long-term complications.( 16 , 17 ) Cardiopulmonary resuscitation is a critical step in prehospital care. Efforts to educate the population and military personnel during a conflict have proven to be essential to reduce mortality and improve outcomes for victims of conflict( 18 ). Moreover, Hospital care has also been affected during the war in Ukraine due to attacks on medical personnel, ambulances, and military and civilian hospitals( 1 ). These attacks directly influence access to timely medical care which is a vital component to prevent deaths. TCCC represents the culmination of advances in medicine during wartime with a systematic approach to care under fire, tactical field fire, and evacuation( 10 ). The TCCC guidelines are designed to address immediate treatment and its complications, such as exsanguination that can lead to cardiovascular failure( 19 ). This dual approach allows wounds to be treated quickly and reduces the risk of cardiovascular complications which account for > 80% of preventable deaths( 20 ) . Conclusion The findings emphasize TCCC transformative potential in conflict zones, demonstrating how digital surveillance of search trends can inform real-time resource allocation and policymaking. Future research should explore the long-term impact of such programs on mortality rates and healthcare infrastructure resilience. Integrating infodemiology into crisis response frameworks could enhance preparedness for future conflicts, ensuring timely and targeted medical interventions. Declarations Funding Statement : This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The study was entirely self-financed by the authors. All costs associated with the development, execution, and dissemination of this research, including materials, data collection, analysis, and manuscript preparation, were covered personally by the authors. Disclosure Statement : The authors declare that there is no conflict of interest regarding the publication of this paper. Authors’ Consent for Publication: We, the authors of the manuscripts entitled “Tactical Care Goes Viral: An Infodemiology Study of Military Medicine Public Interest During the Ukraine Conflict”, hereby declare that we have participated in the conception, design, and execution of the research work. We confirm that we have reviewed the final version of the manuscript and approved it for submission to Discover Health Systems. Furthermore, we understand that this submission implies that the manuscript, in whole or in part, has not been published previously and is not under consideration for publication elsewhere. We affirm that all listed authors have agreed to be named as contributors to this work and have read and approved the final manuscript. Sincerely, Sebastian BALDA MD, Thomas LEONE MD, Flavio VEINTEMILLA-BURGOS MD, Matias PANCHANA-LASCANO MD, Rodolfo KRONFLE MD, Geovanna MINCHALO-OCHOA, MD, Ivo DIAZ-DJEVOICH Acknowledgements : We would like to express our heartfelt appreciation to everyone who contributed to the completion of this research. Their valuable support, guidance, and encouragement have been instrumental in shaping this work. Lastly, our deep appreciation goes to our families and friends for their understanding, encouragement, and unwavering belief in our abilities throughout this journey. Thank you for your support. Permission to reproduce material from other sources: Not applicable. Availability of Data and Materials: The datasets and materials used during this research are available upon reasonable request. Interested researchers can contact Flavio Veintemilla-Burgos ( [email protected] ) for access to the data and materials supporting the findings of this study. Clinical trial registration: Not applicable. Consent to Participate declaration: Not applicable Ethics declaration of Approval: Not applicable Authorship confirmation/contribution statement: Sebastian BALDA: Conceptualization, Methodology, Validation, Formal analysis, Supervision, Visualization, Project administration, Funding acquisition, Writing - original draft, Writing - review & editing, Investigation, Data curation Thomas LEONE: Conceptualization, Methodology, Validation, Formal analysis, Supervision, Project administration, Writing - review & editing Flavio VEINTEMILLA-BURGOS: Conceptualization, Methodology, Validation, Formal analysis, Supervision, Visualization, Project administration, Funding acquisition, Writing - original draft, Writing - review & editing, Investigation, Data curation Mathias PANCHANA-LASCANO: Conceptualization, Methodology, Data curation, Investigation, Validation, Visualization, Writing - original draft, Writing - review & editing, Formal analysis, Project administration, Supervision Rodolfo KRONFLE: Conceptualization, Methodology, Validation, Investigation, Formal analysis, Writing - review & editing, Writing - original draft, Visualization, Data curation Geovanna MINCHALO-OCHOA: Conceptualization, Methodology, Validation, Investigation, Formal analysis, Writing - review & editing, Writing - original draft, Visualization, Data curation Ivo DIAZ-DJEVOICH: Conceptualization, Methodology, Validation, Investigation, Formal analysis, Writing - review & editing, Writing - original draft, Visualization, Data curation Statements of ethical approval No ethical approval is required for this study since the information is completely anonymous and publicly available on the Internet. Disclosure of potential conflicts of interest The authors declare no competing interests. Funding The authors received no specific funding for this work. References Mahase E. Ukraine: Over 700 recorded attacks on health facilities and workers in year since Russia invasion. BMJ [Internet]. 2023 Feb 23 [cited 2024 Nov 7];380:p451. Available from: https://www.bmj.com/content/380/bmj.p451 United Nations Human Rights Office of High Commissioner. United Nations. 2024 [cited 2024 Nov 7]. Ukraine: Türk deplores horrific human cost as Russia’s full-scale invasion enters third year | OHCHR. Available from: https://www.ohchr.org/en/press-releases/2024/02/ukraine-turk-deplores-horrific-human-cost-russias-full-scale-invasion-enters Eysenbach G. Infodemiology and infoveillance: framework for an emerging set of public health informatics methods to analyze search, communication and publication behavior on the Internet. J Med Internet Res [Internet]. 2009 Jan 1 [cited 2024 Nov 7];11(1). Available from: https://pubmed.ncbi.nlm.nih.gov/19329408/ Puryear B, Roarty J, Knight C. EMS Tactical Combat Casualty Care. StatPearls Publishing [Internet]. 2022 Oct 3 [cited 2024 Nov 7]; Available from: https://www.ncbi.nlm.nih.gov/books/NBK532260/ Nuti S V., Wayda B, Ranasinghe I, Wang S, Dreyer RP, Chen SI, et al. The use of google trends in health care research: a systematic review. PLoS One [Internet]. 2014 Oct 22 [cited 2024 Nov 7];9(10). Available from: https://pubmed.ncbi.nlm.nih.gov/25337815/ Christian De Vos. Destruction and Devastation: One Year of Russia’s Assault on Ukraine’s Health Care System - PHR [Internet]. Physicians for Human Rights. New Yprk; 2023 Feb [cited 2024 Nov 9]. Available from: https://phr.org/our-work/resources/russias-assault-on-ukraines-health-care-system/ Vadim Kolisnichenko. Metinvest has already allocated UAH 10.6 million to the development of tactical medicine. GMK CENTER [Internet]. 2023 Sep 16 [cited 2024 Nov 8]; Available from: https://gmk.center/news/metinvest-napravil-na-razvitie-takticheskoj-mediciny-uzhe-10-6-mln-grn/ Kelen G, Sauer LM. Trend analysis of disaster health articles in peer-reviewed publications pre- and post-9/11. Am J Disaster Med [Internet]. 2008 Nov [cited 2024 Nov 7];3(6):369–76. Available from: https://www.unboundmedicine.com/medline/citation/19202890/Trend_analysis_of_disaster_health_articles_in_peer_reviewed_publications_pre__and_post_9/11_ Takahashi K. Tweets about War, Medicine and Humanity: Do You Hear the People Tweet in Ukraine? Tohoku J Exp Med [Internet]. 2023 [cited 2024 Nov 7];259(3):175–6. Available from: https://pubmed.ncbi.nlm.nih.gov/36543244/ Savage LE, Forestier MC, Withers LN, Tien CH, Pannell CD. Tactical combat casualty care in the canadian forces: Lessons learned from the afghan war. Canadian Journal of Surgery. 2011;54(6 SUPPL.). Stannard A, Morrison JJ, Scott DJ, Ivatury RA, Ross JD, Rasmussen TE. The epidemiology of noncompressible torso hemorrhage in the wars in Iraq and Afghanistan. J Trauma Acute Care Surg [Internet]. 2013 Mar [cited 2024 Nov 7];74(3):830–4. Available from: https://pubmed.ncbi.nlm.nih.gov/23425743/ David R. King. David and Goliath: Return of the Humble Tourniquet [Internet]. Boston; 2018 Oct [cited 2024 Nov 7]. Available from: /https://www.massgeneral.org/assets/mgh/pdf/surgery/surgical-society/mgh-surgical-society-fall%202018_vol%2019-no%202_final.pdf Hawk A. How hemorrhage control became common sense. J Trauma Acute Care Surg [Internet]. 2018 Jul 1 [cited 2024 Nov 7];85(1S Suppl 2):S13–7. Available from: https://pubmed.ncbi.nlm.nih.gov/29485427/ Jones VJ. The use of gauze: will it ever change? Int Wound J [Internet]. 2006 Jul 1 [cited 2024 Nov 7];3(2):79–88. Available from: https://onlinelibrary.wiley.com/doi/full/10.1111/j.1742-4801.2006.00215.x Kloner RA. Natural and unnatural triggers of myocardial infarction. Prog Cardiovasc Dis [Internet]. 2006 [cited 2024 Nov 7];48(4):285–300. Available from: https://pubmed.ncbi.nlm.nih.gov/16517249/ Hutchison TN, Krueger CA, Berry JS, Aden JK, Cohn SM, White CE. Venous thromboembolism during combat operations: a 10-y review. J Surg Res [Internet]. 2014 [cited 2024 Nov 7];187(2):625–30. Available from: https://pubmed.ncbi.nlm.nih.gov/24405609/ Martin MJ. Venous thromboembolism after combat amputations: a war we must fight and win. Am J Surg [Internet]. 2016 Aug 1 [cited 2024 Nov 7];212(2):235–7. Available from: https://pubmed.ncbi.nlm.nih.gov/27297255/ Sarhangi F, Gholami HR, Khaghanizade M, Mehri SN. First Aid and Transportation Course Contents Based on Experience gained in the Iran-Iraq War: a Qualitative Study. Trauma Mon [Internet]. 2015 Feb 1 [cited 2024 Nov 7];20(1):36–41. Available from: https://pubmed.ncbi.nlm.nih.gov/25825700/ Butler FK, Bennett B, Wedmore CI. Tactical Combat Casualty Care and Wilderness Medicine: Advancing Trauma Care in Austere Environments. Emerg Med Clin North Am [Internet]. 2017 May 1 [cited 2024 Nov 7];35(2):391–407. Available from: https://pubmed.ncbi.nlm.nih.gov/28411934/ Davis BL, Martin MJ, Schreiber M. Military Resuscitation: Lessons from Recent Battlefield Experience. Curr Trauma Rep [Internet]. 2017 Jun 1 [cited 2024 Nov 9];3(2):156–63. Available from: https://link.springer.com/article/10.1007/s40719-017-0088-9 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 18 Aug, 2025 Reviews received at journal 12 Aug, 2025 Reviewers agreed at journal 23 Jul, 2025 Reviewers agreed at journal 22 Jul, 2025 Reviews received at journal 07 Jul, 2025 Reviewers agreed at journal 24 Jun, 2025 Reviewers invited by journal 18 Jun, 2025 Editor assigned by journal 03 Jun, 2025 Submission checks completed at journal 03 Jun, 2025 First submitted to journal 01 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6794271","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Short Report","associatedPublications":[],"authors":[{"id":472876088,"identity":"bf2d30a2-b23d-40b2-be1c-c956257c2cc0","order_by":0,"name":"Sebastian Balda","email":"","orcid":"","institution":"Catholic University of Santiago de Guayaquil","correspondingAuthor":false,"prefix":"","firstName":"Sebastian","middleName":"","lastName":"Balda","suffix":""},{"id":472876091,"identity":"477b94e1-77a9-4b06-9042-c976d5e3b3ac","order_by":1,"name":"Thomas Leone-Berry","email":"","orcid":"","institution":"Catholic University of Santiago de Guayaquil","correspondingAuthor":false,"prefix":"","firstName":"Thomas","middleName":"","lastName":"Leone-Berry","suffix":""},{"id":472876092,"identity":"6f6c8455-ae8e-4e81-a14e-a4fa243b9b1f","order_by":2,"name":"Flavio Veintemilla-Burgos","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFElEQVRIie2PMUvEMBTHA4FkCXZ9cKX9CikFuaHgV0kROkU4F7lNp3bwxFW/RT+CR8Fb4ii0dKkO5+J2y4E3mERwSotuIvlBwj/wfnnvIeTx/EFopS+hD7FPPg8RvbJhVGHNt4JNJTDEHmyYVr4wCtIKCBvGFYy3MCyb6Gh2u35tF8CC+7fner8AFFTXwq2QYxCqSUnY4FTqwaCXF91KDwbqqXYpJxilPC+LvIRTMjMK6mXRMq1wOHMqDNOdUS61Qj+MEneq6A6TCkuGvMwE0V2wUXhLH/vpLux8ECpLdJfUDpYoSfrQLDWyC6NVvd4vIY7v8pedPGRRtNlsu3cdgurGqTi/4fb+abmBDr+p9ng8nv/PJxx8VX3Rd5XdAAAAAElFTkSuQmCC","orcid":"","institution":"Catholic University of Santiago de Guayaquil","correspondingAuthor":true,"prefix":"","firstName":"Flavio","middleName":"","lastName":"Veintemilla-Burgos","suffix":""},{"id":472876093,"identity":"d987b725-da77-4a86-82fe-affdd2a6fca2","order_by":3,"name":"Matias Panchana-Lascano","email":"","orcid":"","institution":"Catholic University of Santiago de Guayaquil","correspondingAuthor":false,"prefix":"","firstName":"Matias","middleName":"","lastName":"Panchana-Lascano","suffix":""},{"id":472876094,"identity":"78ecf6d9-78f3-4acb-86d3-fd4cac0357ac","order_by":4,"name":"Rodolfo Kronfle-Cordovez","email":"","orcid":"","institution":"Catholic University of Santiago de Guayaquil","correspondingAuthor":false,"prefix":"","firstName":"Rodolfo","middleName":"","lastName":"Kronfle-Cordovez","suffix":""},{"id":472876095,"identity":"a753ba5e-259c-43e7-95ab-d703015bb001","order_by":5,"name":"Geovanna Minchalo-Ochoa","email":"","orcid":"","institution":"Catholic University of Santiago de Guayaquil","correspondingAuthor":false,"prefix":"","firstName":"Geovanna","middleName":"","lastName":"Minchalo-Ochoa","suffix":""},{"id":472876096,"identity":"90fbd79e-5d69-49fd-99aa-2b0e82276e6e","order_by":6,"name":"Ivo Diaz-Djevoich","email":"","orcid":"","institution":"Catholic University of Santiago de Guayaquil","correspondingAuthor":false,"prefix":"","firstName":"Ivo","middleName":"","lastName":"Diaz-Djevoich","suffix":""}],"badges":[],"createdAt":"2025-06-01 07:23:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6794271/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6794271/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85046644,"identity":"80d6fc44-32bc-4307-9638-4d96c8d0dd65","added_by":"auto","created_at":"2025-06-20 10:30:04","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":92725,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"CopiadeFigure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6794271/v1/c2a353cdb5de0698aeb96212.jpg"},{"id":85045850,"identity":"5e53776e-7e0c-44b9-8332-3122006b5f2c","added_by":"auto","created_at":"2025-06-20 10:22:04","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":104033,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"CopiadeFigure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6794271/v1/82aa4faa0283d56e450018c4.jpg"},{"id":85046646,"identity":"80cac92c-a4aa-48e7-b3b0-ac2eae41fc0d","added_by":"auto","created_at":"2025-06-20 10:30:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":758859,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6794271/v1/3d46886e-1c60-44af-89dc-5a059f000626.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Tactical Combat Casualty Care Goes Viral: An Infodemiology Study of Military Medicine Public Interest During the Ukraine Conflict","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe Ukraine war continues to have a serious impact on local people\u0026rsquo;s lives. Medical healthcare services have been severed, with more than 700 reported attacks on healthcare facilities since the start of the war. In 2022, there were 292 attacks on hospitals and clinics, 181 attacks on other health infrastructure, and 65 attacks on ambulances. There were also 86 attacks on healthcare workers, with 62 killed and 52 injured (1). The Office of the United Nations High Commissioner for Human Rights verified 10,582 deaths of civilians in Ukraine as of February 2024(2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhile we cannot personally attest to whatever\u0026rsquo;s happening on a day-by-day basis in Ukraine\u0026apos;s population, Google Trends (GTr) allows us to measure the level of interest on certain topics in specific locations and times. According to Eysenbach, Infodemiology is \u0026ldquo;the science of distribution and determinants of information in an electronic medium, specifically the Internet, or in a population, with the ultimate aim to inform public health and public policy\u0026rdquo;(3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWartime medicine is a relevant aspect of healthcare in dire need due to the emergency in this population\u0026rsquo;s care. At times of war, complications such as hemorrhages persist as the main cause of death (4). According to this context, \u0026nbsp;the study focused on Tactical Combat Casualty Care (TCCC) related topics and aims to analyze trends of Internet users\u0026rsquo; interest health seeking patterns during a 21st century war plagued Ukraine using the Google Trends tool.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy design:\u003c/p\u003e\n\u003cp\u003eIn this retrospective study, Tactical Combat Casualty Care (TCCC) EMS guidelines were used to select key terms related to Care Under Fire, Tactical Field Care, and Tactical Evacuation Care. the selected search topics were categorized as treatment and etiology accordingly. Treatment-related topics included: Amputation, Hospital, Dressing, Tourniquet, Military Hospital, Cardiopulmonary Resuscitation, and Tactical Combat Casualty Care. Etiology-related topics included: Deep Vein Thrombosis, Exsanguination, Hemorrhage, and Wounded in Combat. These topics were extracted from Google Trends as \u0026quot;topics,\u0026quot; ensuring that search interest was captured across all relevant languages referring to the same concept. Data collection was limited to searches originating from Ukrainian territory between January 1, 2020, and January 1, 2024, covering the two years before and after the onset of the Russian invasion of Ukraine. Search volume was measured using Relative Search Volume (RSV). RSV data was downloaded and processed using SPSS (version 21.0). Pre-war and post-war RSV values were compared using Welch\u0026apos;s one-way ANOVA for normally distributed data and the Wilcoxon signed-rank test for non-normally distributed data.\u003c/p\u003e\n\u003cp\u003eData System:\u003c/p\u003e\n\u003cp\u003eGTr is a free public tool for analyzing searches on the Google search engine for specific topics and terms. It provides a categorized and anonymous database whose main metric is RSV. GTr has been used in health care studies from 2009 to 2013 and 34% of those studies were for surveillance. Among surveillance studies, 92% were validated against a reference standard data source, and 80% of studies using correlation had a correlation statistic (5). The datasets generated and/or analysed during the current study are available in the Google Trends repository, https://trends.google.es/trends/.\u003c/p\u003e\n\u003cp\u003eData collection/ processing\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData on Gtr is collected continuously, and RSV results are reported daily. The data was downloaded from the GTr database on April 9, 2024. The period from which data was gathered is January 1, 2020, until January 1, 2024. This was made to analyze two years before and two years during the invasion.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe main measure of interest was RSV, a normalized measure of interest over time. RSV is essentially a proportion of the search interest in a specific term relative to all Google searches during the specified period and geographic region. RSV value oscillates between 100 and 0 in descending order, reflecting the relative popularity of specific search terms within the selected timeframe and geographic scope (3). A higher value means a higher popularity. The data was downloaded as Comma-separated values (CSV) and statistical evaluations were processed using Statistical Package for Social Science (version 21.0; SPSS, Chicago, USA).\u003c/p\u003e\n\u003cp\u003eOutcomes:\u003c/p\u003e\n\u003cp\u003eThis study includes, in detail, the growth and peaks of RSV on a scale from 0 to 100.\u003c/p\u003e\n\u003cp\u003eAnalysis:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA mean RSV value was calculated considering values during the study timeframe as the Russian invasion of Ukraine occurred on the 21 of February 2022 values were classified before, and after this event as RSV Prewar average ,and RSV Postwar average.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA Kolmogorov-Smirnov test was performed to assess the distribution, in which a p \u0026lt;0.05 was considered an abnormal distribution. For the normally distributed Welch\u0026apos;s One-way ANOVA test was performed to analyze the difference in the search interest of the selected topics by comparing the search interest divided into pre warfare and post warfare groups a p \u0026lt;0.05 was considered statistically significant and an F value was obtained. For abnormally distributed variables, a Wilcoxon signed rank test was performed, considering statistically significant \u0026nbsp;p\u0026lt;0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003ePublic interest in treatment-related topics surged post-invasion, aligning with Tactical Combat Casualty Care (TCCC) principles. The results of the Kolmogorov Smirnov test showcase that hospital, and amputation were normally distributed while all the other variables were abnormally distributed. In Care Under Fire (immediate hemorrhage control), Tourniquet searches rose sharply (RSV 12.8 to 38.3;p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Tactical Field Care drove spikes in Dressing (RSV 26.1 to 53.4; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and Cardiopulmonary Resuscitation (RSV 0.2 to 28; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Tactical Evacuation Care (advanced transport) saw increased searches for Hospital (RSV 62.4 to 72.3 ; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and Amputation (RSV 44.6 to 54; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) Military Hospital (RSV 30.8 to 45.5; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) .\u003c/p\u003e \u003cp\u003eOverall, TCCC searches surged from (RSV 0.3 to 47.2; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), peaking in 2023 alongside allied training efforts (Fig.\u0026nbsp;1). Searches mirrored acute combat injuries. Wounded in Combat skyrocketed (RSV 7.4 to 54.5; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while Hemorrhage (RSV 61.2 to 67.8; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and Exsanguination (RSV 32.6 to 40.2; p\u0026thinsp;=\u0026thinsp;0.031) reflected bleeding-related urgency. Deep Vein Thrombosis declined (RSV 49.9 to 40.8; p\u0026thinsp;=\u0026thinsp;0.017), overshadowed by trauma priorities(Fig.\u0026nbsp;2).\u003c/p\u003e \u003cp\u003eAnalysis of Figs.\u0026nbsp;1 and 2 reveals distinct search trends: trauma care strategies such as Amputation, Hospital, and Tactical Combat Casualty Care (TCCC) surged in 2023 a year after the conflict began coinciding with the phased rollout of allied-led TCCC training programs. These programs emphasized critical protocols: hemorrhage control (Care Under Fire), wound stabilization (Tactical Field Care), and transport logistics (Tactical Evacuation Care). In contrast, acute injury-related terms like Wounded in Combat, Hemorrhage, and Exsanguination spiked immediately in 2022 as the invasion escalated. An explanation for this temporal disconnect could be that while urgent injury-related queries rose at the war\u0026rsquo;s onset, treatment-focused searches increased later, driven by structured training dissemination despite immediate medical needs existing since 2022.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWar alters aspects of life and shifts people's priorities. Since healthcare accessibility has taken a heavy toll, people\u0026rsquo;s interest adapts to the current context (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).The war in Ukraine influences the interest in medical web searches. Such as, hospital and hemorrhage as they were the most searched topics in the study as medical facilities were attacked during war and bleeding became a major concern for the Ukrainian population.\u003c/p\u003e \u003cp\u003eThere was a notable increase in searches for treatment-related terms during wartime. In searches for treatment, \u0026ldquo;Amputation\u0026rdquo; and \u0026ldquo;Hospital\u0026rdquo; search interest rose the most, reflecting the heightened interest in these topics. However, we cannot assume the intent behind these searches. This may be a key factor for research studies, underscoring the need for studies and interventions that address both immediate concerns and underlying health issues for better public health outcomes.\u003c/p\u003e \u003cp\u003eThe changes in RSV on topics related to etiology from 2020 to 2024 in Ukraine as shown in Fig.\u0026nbsp;2, followed an interesting pattern when wounded in combat search peaked also did the other etiologies such as hemorrhage and exsanguination dramatically increasing after the Russian invasion of Ukraine began showcasing a change in search pattern and use of the internet for immediate medical needs in times of conflict.\u003c/p\u003e \u003cp\u003eHeightened interest in bleeding related topics after the start of the war can also suggest the relevance of an organized emergency medical service in war plagued countries. To limit the number of deaths to crossfires, avoiding the loss of innocent people\u0026rsquo;s lives. One of the branches of emergency medical services is Tactical Combat Casualty Care (TCCC). Its primary objectives consist of providing early medical care to limit casualties during combat. Since its implementation, US military survival rates have reached historic heights. Ukraine, allied with the US, shows a growing interest in TCCC (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAs illustrated in Fig.\u0026nbsp;1, the TCCC influences the RSV of topics related to treatment from 2020 to 2024 in Ukraine. When searches on TCCC peaked in 2023 also the searches for hospital, cardiopulmonary resuscitation, amputation, and military hospital. Although the Russian invasion began in 2022, an explanation for this could be the direct influence of allied forces training the Ukrainian population on TCCC(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), influencing the search pattern for other topics. TCCC is directed to the medical and nonmedical population to improve mortality rates on preventable deaths. This finding is a positive sign that training has a positive effect on the population's health education, and it could be a potentially beneficial policy for other wars in the future.\u003c/p\u003e \u003cp\u003eWar-related medical care has been a topic of interest even in times of peace. According to Gabor and Lauren, ever since the calamity of 9/11 medical journals have increased their interest in publishing disaster medicine articles (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). However, too little has been written about the shift in public interest regarding medicine in times of war. A study by Takahashi focuses on people's medical inquisitiveness via tweets regarding \u0026ldquo;mental health\u0026rdquo; (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eManagement of cardiovascular injuries and complications during wartime is essential to reduce mortality and improve survival. Treatment strategies such as cardiopulmonary resuscitation, amputations, tourniquets, and related medical supplies, for instance, dressings have evolved dramatically through lessons learned from modern conflicts in wars, such as Iraq and Afghanistan. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eLack of hemorrhage control and immediate care are among the leading causes of death during armed conflict. (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) During the Global War on Terror, many lives were lost to exsanguination before medical care could be reached, highlighting the importance of prehospital treatment for hemorrhage control. One of the solutions implemented was the reintroduction and widespread training in the use of tourniquets which dramatically reduced deaths from exsanguination (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe tourniquet is an intervention originally implemented by Jean-Louis Petit and was refined by centuries of military experience to form a core part of what is now known as Tactical Combat Casualty Care (TCCC)(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Therefore, the use of tourniquets combined with gauze and dressings is essential in wound management, becoming a fundamental pillar in medicine during war. (\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eCardiovascular stress and thromboembolic complications from immediate injuries contribute greatly to cardiovascular conditions that can severely impact the health outcomes of those affected(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).There is a significant increase in the incidence of amputations during armed conflict, as evidenced in the war in Iraq and Afghanistan. Appropriate management of amputations is necessary to prevent immediate and long-term complications.(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eCardiopulmonary resuscitation is a critical step in prehospital care. Efforts to educate the population and military personnel during a conflict have proven to be essential to reduce mortality and improve outcomes for victims of conflict(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Moreover, Hospital care has also been affected during the war in Ukraine due to attacks on medical personnel, ambulances, and military and civilian hospitals(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). These attacks directly influence access to timely medical care which is a vital component to prevent deaths.\u003c/p\u003e \u003cp\u003eTCCC represents the culmination of advances in medicine during wartime with a systematic approach to care under fire, tactical field fire, and evacuation(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The TCCC guidelines are designed to address immediate treatment and its complications, such as exsanguination that can lead to cardiovascular failure(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). This dual approach allows wounds to be treated quickly and reduces the risk of cardiovascular complications which account for \u0026gt;\u0026thinsp;80% of preventable deaths(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) .\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe findings emphasize TCCC transformative potential in conflict zones, demonstrating how digital surveillance of search trends can inform real-time resource allocation and policymaking. Future research should explore the long-term impact of such programs on mortality rates and healthcare infrastructure resilience. Integrating infodemiology into crisis response frameworks could enhance preparedness for future conflicts, ensuring timely and targeted medical interventions.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding Statement\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The study was entirely self-financed by the authors. All costs associated with the development, execution, and dissemination of this research, including materials, data collection, analysis, and manuscript preparation, were covered personally by the authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure Statement\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eThe authors declare that there is no conflict of interest regarding the publication of this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Consent for Publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe, the authors of the manuscripts entitled \u0026ldquo;Tactical Care Goes Viral: An Infodemiology Study of Military Medicine Public Interest During the Ukraine Conflict\u0026rdquo;, hereby declare that we have participated in the conception, design, and execution of the research work. We confirm that we have reviewed the final version of the manuscript and approved it for submission to Discover Health Systems. Furthermore, we understand that this submission implies that the manuscript, in whole or in part, has not been published previously and is not under consideration for publication elsewhere.\u003c/p\u003e\n\u003cp\u003eWe affirm that all listed authors have agreed to be named as contributors to this work and have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eSincerely,\u003c/p\u003e\n\u003cp\u003eSebastian BALDA MD,\u003c/p\u003e\n\u003cp\u003eThomas LEONE MD,\u003c/p\u003e\n\u003cp\u003eFlavio VEINTEMILLA-BURGOS MD,\u003c/p\u003e\n\u003cp\u003eMatias PANCHANA-LASCANO MD,\u003c/p\u003e\n\u003cp\u003eRodolfo KRONFLE MD,\u003c/p\u003e\n\u003cp\u003eGeovanna MINCHALO-OCHOA, MD,\u003c/p\u003e\n\u003cp\u003eIvo DIAZ-DJEVOICH\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eWe would like to express our heartfelt appreciation to everyone who contributed to the completion of this research. Their valuable support, guidance, and encouragement have been instrumental in shaping this work.\u003c/p\u003e\n\u003cp\u003eLastly, our deep appreciation goes to our families and friends for their understanding, encouragement, and unwavering belief in our abilities throughout this journey.\u003c/p\u003e\n\u003cp\u003eThank you for your support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePermission to reproduce material from other sources:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets and materials used during this research are available upon reasonable request. Interested researchers can contact Flavio Veintemilla-Burgos ([email protected]) for access to the data and materials supporting the findings of this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial registration:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate declaration:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declaration of Approval:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthorship confirmation/contribution statement:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSebastian BALDA:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization, Methodology, Validation, Formal analysis, Supervision, Visualization, Project administration, Funding acquisition, Writing - original draft, Writing - review \u0026amp; editing, Investigation, Data curation\u003cstrong\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThomas LEONE:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization, Methodology, Validation, Formal analysis, Supervision, Project administration, Writing - review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFlavio VEINTEMILLA-BURGOS:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization, Methodology, Validation, Formal analysis, Supervision, Visualization, Project administration, Funding acquisition, Writing - original draft, Writing - review \u0026amp; editing, Investigation, Data curation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMathias PANCHANA-LASCANO:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization, Methodology, Data curation, Investigation, Validation, Visualization, Writing - original draft, Writing - review \u0026amp; editing, Formal analysis, Project administration, Supervision\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRodolfo KRONFLE:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization, Methodology, Validation, Investigation, Formal analysis, Writing - review \u0026amp; editing, Writing - original draft, Visualization, Data curation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGeovanna MINCHALO-OCHOA:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization, Methodology, Validation, Investigation, Formal analysis, Writing - review \u0026amp; editing, Writing - original draft, Visualization, Data curation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIvo DIAZ-DJEVOICH:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization, Methodology, Validation, Investigation, Formal analysis, Writing - review \u0026amp; editing, Writing - original draft, Visualization, Data curation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatements of ethical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo ethical approval is required for this study since the information is completely anonymous and publicly available on the Internet.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure of potential conflicts of interest \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no specific funding for this work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMahase E. Ukraine: Over 700 recorded attacks on health facilities and workers in year since Russia invasion. BMJ [Internet]. 2023 Feb 23 [cited 2024 Nov 7];380:p451. Available from: https://www.bmj.com/content/380/bmj.p451\u003c/li\u003e\n\u003cli\u003eUnited Nations Human Rights Office of High Commissioner. United Nations. 2024 [cited 2024 Nov 7]. Ukraine: T\u0026uuml;rk deplores horrific human cost as Russia\u0026rsquo;s full-scale invasion enters third year | OHCHR. Available from: https://www.ohchr.org/en/press-releases/2024/02/ukraine-turk-deplores-horrific-human-cost-russias-full-scale-invasion-enters\u003c/li\u003e\n\u003cli\u003eEysenbach G. Infodemiology and infoveillance: framework for an emerging set of public health informatics methods to analyze search, communication and publication behavior on the Internet. J Med Internet Res [Internet]. 2009 Jan 1 [cited 2024 Nov 7];11(1). Available from: https://pubmed.ncbi.nlm.nih.gov/19329408/\u003c/li\u003e\n\u003cli\u003ePuryear B, Roarty J, Knight C. EMS Tactical Combat Casualty Care. StatPearls Publishing [Internet]. 2022 Oct 3 [cited 2024 Nov 7]; Available from: https://www.ncbi.nlm.nih.gov/books/NBK532260/\u003c/li\u003e\n\u003cli\u003eNuti S V., Wayda B, Ranasinghe I, Wang S, Dreyer RP, Chen SI, et al. The use of google trends in health care research: a systematic review. PLoS One [Internet]. 2014 Oct 22 [cited 2024 Nov 7];9(10). Available from: https://pubmed.ncbi.nlm.nih.gov/25337815/\u003c/li\u003e\n\u003cli\u003eChristian De Vos. Destruction and Devastation: One Year of Russia\u0026rsquo;s Assault on Ukraine\u0026rsquo;s Health Care System - PHR [Internet]. Physicians for Human Rights. New Yprk; 2023 Feb [cited 2024 Nov 9]. Available from: https://phr.org/our-work/resources/russias-assault-on-ukraines-health-care-system/\u003c/li\u003e\n\u003cli\u003eVadim Kolisnichenko. Metinvest has already allocated UAH 10.6 million to the development of tactical medicine. GMK CENTER [Internet]. 2023 Sep 16 [cited 2024 Nov 8]; Available from: https://gmk.center/news/metinvest-napravil-na-razvitie-takticheskoj-mediciny-uzhe-10-6-mln-grn/\u003c/li\u003e\n\u003cli\u003eKelen G, Sauer LM. Trend analysis of disaster health articles in peer-reviewed publications pre- and post-9/11. Am J Disaster Med [Internet]. 2008 Nov [cited 2024 Nov 7];3(6):369\u0026ndash;76. Available from: https://www.unboundmedicine.com/medline/citation/19202890/Trend_analysis_of_disaster_health_articles_in_peer_reviewed_publications_pre__and_post_9/11_\u003c/li\u003e\n\u003cli\u003eTakahashi K. Tweets about War, Medicine and Humanity: Do You Hear the People Tweet in Ukraine? Tohoku J Exp Med [Internet]. 2023 [cited 2024 Nov 7];259(3):175\u0026ndash;6. Available from: https://pubmed.ncbi.nlm.nih.gov/36543244/\u003c/li\u003e\n\u003cli\u003eSavage LE, Forestier MC, Withers LN, Tien CH, Pannell CD. Tactical combat casualty care in the canadian forces: Lessons learned from the afghan war. Canadian Journal of Surgery. 2011;54(6 SUPPL.). \u003c/li\u003e\n\u003cli\u003eStannard A, Morrison JJ, Scott DJ, Ivatury RA, Ross JD, Rasmussen TE. The epidemiology of noncompressible torso hemorrhage in the wars in Iraq and Afghanistan. J Trauma Acute Care Surg [Internet]. 2013 Mar [cited 2024 Nov 7];74(3):830\u0026ndash;4. Available from: https://pubmed.ncbi.nlm.nih.gov/23425743/\u003c/li\u003e\n\u003cli\u003eDavid R. King. David and Goliath: Return of the Humble Tourniquet [Internet]. Boston; 2018 Oct [cited 2024 Nov 7]. Available from: /https://www.massgeneral.org/assets/mgh/pdf/surgery/surgical-society/mgh-surgical-society-fall%202018_vol%2019-no%202_final.pdf\u003c/li\u003e\n\u003cli\u003eHawk A. How hemorrhage control became common sense. J Trauma Acute Care Surg [Internet]. 2018 Jul 1 [cited 2024 Nov 7];85(1S Suppl 2):S13\u0026ndash;7. Available from: https://pubmed.ncbi.nlm.nih.gov/29485427/\u003c/li\u003e\n\u003cli\u003eJones VJ. The use of gauze: will it ever change? Int Wound J [Internet]. 2006 Jul 1 [cited 2024 Nov 7];3(2):79\u0026ndash;88. Available from: https://onlinelibrary.wiley.com/doi/full/10.1111/j.1742-4801.2006.00215.x\u003c/li\u003e\n\u003cli\u003eKloner RA. Natural and unnatural triggers of myocardial infarction. Prog Cardiovasc Dis [Internet]. 2006 [cited 2024 Nov 7];48(4):285\u0026ndash;300. Available from: https://pubmed.ncbi.nlm.nih.gov/16517249/\u003c/li\u003e\n\u003cli\u003eHutchison TN, Krueger CA, Berry JS, Aden JK, Cohn SM, White CE. Venous thromboembolism during combat operations: a 10-y review. J Surg Res [Internet]. 2014 [cited 2024 Nov 7];187(2):625\u0026ndash;30. Available from: https://pubmed.ncbi.nlm.nih.gov/24405609/\u003c/li\u003e\n\u003cli\u003eMartin MJ. Venous thromboembolism after combat amputations: a war we must fight and win. Am J Surg [Internet]. 2016 Aug 1 [cited 2024 Nov 7];212(2):235\u0026ndash;7. Available from: https://pubmed.ncbi.nlm.nih.gov/27297255/\u003c/li\u003e\n\u003cli\u003eSarhangi F, Gholami HR, Khaghanizade M, Mehri SN. First Aid and Transportation Course Contents Based on Experience gained in the Iran-Iraq War: a Qualitative Study. Trauma Mon [Internet]. 2015 Feb 1 [cited 2024 Nov 7];20(1):36\u0026ndash;41. Available from: https://pubmed.ncbi.nlm.nih.gov/25825700/\u003c/li\u003e\n\u003cli\u003eButler FK, Bennett B, Wedmore CI. Tactical Combat Casualty Care and Wilderness Medicine: Advancing Trauma Care in Austere Environments. Emerg Med Clin North Am [Internet]. 2017 May 1 [cited 2024 Nov 7];35(2):391\u0026ndash;407. Available from: https://pubmed.ncbi.nlm.nih.gov/28411934/\u003c/li\u003e\n\u003cli\u003eDavis BL, Martin MJ, Schreiber M. Military Resuscitation: Lessons from Recent Battlefield Experience. Curr Trauma Rep [Internet]. 2017 Jun 1 [cited 2024 Nov 9];3(2):156\u0026ndash;63. Available from: https://link.springer.com/article/10.1007/s40719-017-0088-9\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-health-systems","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"dihs","sideBox":"Learn more about [Discover Health Systems](https://www.springer.com/44250)","snPcode":"44250","submissionUrl":"https://submission.nature.com/new-submission/44250/3","title":"Discover Health Systems","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Tactical Combat Casualty Care, Military Medicine, Public Health, Ukraine, Russian invasion, Infodemiology","lastPublishedDoi":"10.21203/rs.3.rs-6794271/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6794271/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe Ukraine conflict has profoundly disrupted healthcare, with over 700 attacks on medical facilities reported since Russia\u0026rsquo;s 2022 invasion. This Infodemiological study analyzes wartime public health-seeking behavior through Google Trends data.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eUsing Tactical Combat Casualty Care (TCCC) guidelines, we categorized Ukrainian-territory searches (January 2020\u0026ndash;January 2024) into \u003cem\u003etreatment-related\u003c/em\u003e (Amputation, Tourniquet, Cardiopulmonary Resuscitation, TCCC) and \u003cem\u003eetiology-related\u003c/em\u003e terms (Wounded in Combat, Hemorrhage, Deep Vein Thrombosis). Relative Search Volume (RSV) pre-invasion and post-invasion was statistically compared using Welch\u0026rsquo;s ANOVA (normally distributed data) or Wilcoxon signed-rank tests (non-normal distributions; SPSS v21.0).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAnalysis revealed a critical temporal disconnect: Etiology-related searches surged immediately post-invasion in 2022, evidenced by \"Wounded in Combat\" (RSV 7.4 to 54.5; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and \"Hemorrhage\" (RSV 61.2 to 67.8; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), reflecting acute injury crises. In contrast, treatment-related terms peaked in 2023, aligning with allied TCCC training and searches in which TCCC interest rose dramatically (RSV 0.3 to 47.2; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001); Other searches increase as \"Tourniquet\" (RSV 12.8 to 38.3; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and \"Cardiopulmonary Resuscitation\" (RSV 0.2 to 28; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Moreover, \"Deep Vein Thrombosis\" queries declined (RSV 49.9 to 40.8; p\u0026thinsp;=\u0026thinsp;0.017), suggesting a population-level shift from chronic to acute trauma priorities.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe delayed surge in treatment-related searches directly correlates with TCCC program implementation, demonstrating its capacity to shape population health responses during conflict. These findings support integrating TCCC into public health policy for future wars and highlight infodemiology\u0026rsquo;s utility in real-time crisis resource allocation.\u003c/p\u003e","manuscriptTitle":"Tactical Combat Casualty Care Goes Viral: An Infodemiology Study of Military Medicine Public Interest During the Ukraine Conflict","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-20 10:13:59","doi":"10.21203/rs.3.rs-6794271/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-18T11:36:53+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-12T15:01:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"279487107713462886840571214619579047202","date":"2025-07-23T20:33:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"45452320162369361685858375883591715033","date":"2025-07-22T16:40:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-07T17:10:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"153719109805985451613466614606650356125","date":"2025-06-24T17:43:22+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-18T05:29:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-03T14:15:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-03T14:09:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Health Systems","date":"2025-06-01T07:07:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-health-systems","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"dihs","sideBox":"Learn more about [Discover Health Systems](https://www.springer.com/44250)","snPcode":"44250","submissionUrl":"https://submission.nature.com/new-submission/44250/3","title":"Discover Health Systems","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9b1a61f9-3fa4-42aa-a5e1-71bcad909e9a","owner":[],"postedDate":"June 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-30T06:53:55+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-20 10:13:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6794271","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6794271","identity":"rs-6794271","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}