A disaster is a string of bottlenecks – LIV 2025

On April 9, the Västra Götaland Region (VGR) conducted a major total defense exercise — LIV 2025. This recurring format had been on hold for a few years due to the COVID-19 pandemic. This year, the exercise was held in Trollhättan/NÄL, where two major simulated accidents involved approximately 200 casualties. The focus was on testing the healthcare system’s ability to manage a mass casualty incident in coordination with other emergency actors. The hospital’s own leadership and coordination capabilities were also put to the test.

CKM assigned to evaluate LIV 2025

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To strengthen the learning from the exercise, the VGR Group Office commissioned an independent and research-based evaluation from the Centre for Disaster Medicine, focusing on the pre-hospital response and civil-military cooperation.

“Our assignment includes documenting, analyzing, and compiling lessons from the prehospital parts of the exercise, with the goal of improving VGR’s future preparedness, leadership, and coordination in the event of serious incidents and crises. The final report is due by October 15, 2025,” says Yohan Robinson, Director of CKM.

During the exercise, CKM deployed around 30 observers at both civilian and military prehospital injury sites, as well as within the hospital’s ambulance bay, emergency department, and radiology unit.

Relying on what’s in our muscle memory

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Healthcare systems rarely train for large-scale emergencies or disaster scenarios. An exercise of LIV’s magnitude — involving key collaboration partners like military medical units, fire and rescue services, police, civilian prehospital care, and emergency dispatch services — is exceptionally rare.

“If we want to be able to handle mass casualty scenarios, we can’t rely on the idea of ‘rising to the occasion with heroics.’ Instead, we must recognize that we’ll fall back on our muscle memory. That’s why drills, training, and testing our capacity are essential, and we need to do much more of it,” says Jonas Zimmerman, resident physician at Sahlgrenska University Hospital and lead researcher at CKM for this evaluation.

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What do you hope to gain from the evaluation?

“There’s a saying that a disaster is a strain of bottlenecks. Through our evaluation, I hope to identify which bottlenecks cause the most serious problems in Swedish healthcare and in collaboration with the key actors involved. This knowledge will help us improve and ultimately save more lives.”

Jonas is very pleased with how the day went and feels a deep sense of pride in all the instructors and observers who carried out their tasks with excellence.

“Without their independent action, problem-solving mindset, and immense expertise, nothing would have worked. They are the real heroes of this exercise!” 

Comparing civilian and military patient flows

Civil-military collaboration is widely recognized as a challenge around the world, and significant knowledge gaps remain. One major issue is the “culture gap” that often keeps civilian and military actors at arm’s length.

“CKM has long contributed to advancing knowledge in civil-military collaboration and has been designated by the National Board of Health and Welfare as a center of expertise in total defense medicine. This includes research questions related to increasing capacity through civil-military cooperation,” says Yohan Robinson.

In Sweden, there are no military hospitals, meaning all injured military personnel rely entirely on the civilian healthcare system. That makes it critical for both sectors to train together and speak the same operational language. CKM has previously published several studies related to the LIV exercises.

“This year, we’re focusing on the prehospital flow — comparing the civilian and military tracks. We used identical patient scenarios in both flows. Key factors like survival rates, time from incident site to hospital, and triage accuracy will give us unique insights into decision-making processes. These findings will help shape new recommendations,” Robinson explains.

WHO observer Souheil Reaiche on site

Souheil Reaiche from the WHO’s EMT Secretariat was also present during the exercise. At WHO, he leads the coordination of deployments and support for surge operations. His work includes overseeing EMT deployments, helping countries build national EMT systems, promoting civil-military collaboration, and ensuring EMT coordination cells are activated and function effectively during emergencies.

“LIV 2025 gave me valuable insights into how coordination works under operational pressure and in complex environments. The exercise confirmed some assumptions while also highlighting areas for improvement,” says Souheil Reaiche.

Reaiche gathered crucial and rare observations for WHO’s thematic working group on civil-military medical coordination, which he supports in collaboration with the University of Gothenburg. Strengthening coordination and interaction between sectors, he says, is essential for ensuring principled, coordinated, and effective emergency responses.

“The exercise also reinforced the importance of supporting countries in activating EMT Coordination Cells (EMTCC) and integrating EMTs into national crisis preparedness systems.”

CKM may contribute knowledge internationally

“WHO’s EMT initiative is now considering using CKM for training and exercises in civil-military collaboration — largely because CKM holds genuine expertise in the field,” concludes Yohan Robinson.

Text: Susanne Lj Westergren