Key PointsQuestionHow can medical evacuation trains be implemented in a war zone and what type of patients can be expected?FindingsThis case series describes medical evacuation by train during the 2022 Ukraine conflict using 2 trains. Over 8 months, the medical trains made 74 journeys, evacuating 2481 patients from 11 cities close to the frontline; during this period, the most common type of patients transported changed from trauma-related casualties to patients with medical and nonacute reasons for referral.MeaningThe findings of this study suggest that medical evacuation by train can be feasible in a conflict zone with a preexisting railway network, if adapted to local conditions and an evolving patient population.