乌克兰战争的教训及其在未来与近邻对手冲突中的应用——PMC

![](/media/202412//1733466109.9239533.png)把医疗靴子放在上面

地面：从战争中吸取的经验教训

在乌克兰和申请中

![](/media/202412//1733466109.985454.png)未来与近同行的冲突 对手

**全球战争对恐怖主义和恐怖** **与近乎同辈的冲突**

**对手**

全球反恐战争：战争的威胁

在GWOT期间，美国和盟军的伤害一般都是来自于 小口径火器、简易爆炸装置（ied）和

来自短程迫击炮和火箭的间接火力。3有一个

据估计，美国有7076名美国人死亡，53337人受伤

这20年。4.伤害的爆炸机制最大 部分战斗伤口在GWOT，约占

79%的战场受伤。在几乎任何被叛乱分子的袭击中，

美军很快就在战场上占据了主导地位，并能够做到这一点 在上级火力或近距离伞下疏散伤亡人员

空中支援5.总的来说，在GWOT期间的威胁是有限的

持续时间和范围。6-8也有充分的证据证明，高质量的医疗质量 可以在战场上或战场附近迅速、安全地进行护理。

由于空中疏散能力，病人可以被带来

快速到达治疗设施。进一步的医疗资产已被删除 从冲突中看，他们就越安全，即使他们还在

作战战区。9最后，损伤控制复苏

已被修改为包括早期使用新鲜的全血和

改进了治疗方案，减少了血液制品的总量 需要拯救生命。10-12

![](/media/202412//1733466109.9981456.png)

近距离对手的威胁：更大 致命性

简易爆炸装置在GWOT造成了重大伤亡。他们可能会受伤

多名人员同时工作，甚至使车辆瘫痪。与...比较 在叛乱/恐怖主义部队中，npa有更重和更长的射程 武器装备，从而增加了发病率和死亡率

战斗伤亡。虽然可以安排简易爆炸装置提供

连续的爆炸细胞增加了它们的致死率，这些配置是

很少在GWOT工作。在乌克兰，俄罗斯军队已经做到了

使用了现代便携式反坦克导弹与先进的双枚导弹 形状装药或热压弹头或热压火箭火炮

高射炮火网这些热压武器会引起钝性和穿透性

伤口和大量的热伤。14.最近发生的一个事件正在使用 这种武器造成12人立即死亡

距离撞击点20米以内。一个伤员离这里60米远 撞击点遭受了80%的全身表面积烧伤

在72小时内被证明是致命的 复苏的尝试。

俄罗斯人使用燃烧弹会导致严重的深度烧伤 伤害、有机磷中毒等其他毒性作用

与燃烧的物质有关的蒸汽。15烧伤护理

伤亡人员造成了重大的后勤和医疗负担，因为 护理的复杂性和广泛的复苏的需要。这个

强调了计划治疗重大的热伤/烧伤损伤的必要性 未来的战斗。

已被俄罗斯广泛使用的现代反坦克导弹

有一个接近+75%的死亡率时，雇用对人员或 轻型装甲车辆，因为它们是用来用于对抗

坦克或掩体。美国军事人员遇到了这些武器 在GWOT期间很少。他们看起来更像是一个

在此NPA冲突中频繁发生。17.他们已经受伤了

这些都是毁灭性的，而且存活率明显低于这些数字 如火炮和迫击炮等非方向性爆炸伤害。13

此外，在这场冲突中，俄罗斯军队几乎一直在开火 每天发射6万发炮弹。这代表了美国的一场大火

自第二次世界大战以来，军队从未出现过。

在乌克兰，俄罗斯军队经常使用区域拒绝弹药，例如

反坦克和杀伤人员地雷。这些弹药是用

标准化的，一致的建设完成了一个更大的

规模因此，它们更容易获得，在操作上更可靠，更有效，

和可部署的。根据定义，在GWOT中使用的简易爆炸装置是即兴制作的 因此，其可靠性存在问题。它们通常由一系列的

可用的爆炸装置和使用的密度要低得多

与广泛的NPA就业情况相比，特定区域内的设备。

对医疗资产的安全保障 战场

快速疏散病人的能力和反应的安全

医疗队因为更好的NPA武器而受到损害。这个

俄国军队精确打击远远超出前线的能力 与远程武器如巡航导弹或无人机意味着

对受伤人员的威胁只有在病人距离很远时才会减弱 从冲突战区移除(图。1).在乌克兰，医院和

医疗设施成为袭击目标，并被袭击到西部的日托米尔 位于俄罗斯边境以西约400公里处。2).

此外，俄罗斯的导弹袭击已经发生在25公里的范围内 波兰与乌克兰边境，这意味着俄罗斯的武器可以袭击

在乌克兰的任何一个城市的医疗中心。相比之下，在GWOT考试中，

叛乱军火库的占地面积约为20公里。当

应用于未来可能与npa的冲突，很可能是

敌人的军火库将能够到达距离数百公里处 前线例如，中国的CJ-10巡航导弹能够实现

携带一枚1000磅的弹头超过1500公里。20.如果一个手术是要 在正向环境中进行治疗，患者将需要接受治疗

在坚固和受保护设施的攻击威胁下

直到病人被完全从手术室移出手术室。

图1。

距离的线性效应。这个数字突出了两者之间的关系 医疗直升机单位距离敌人位置的相对安全程度

变化蓝线显示了GWOT中的关系

强调了在小距离下安全的快速增加

从敌人的位置。红线表示NPA中的关系 冲突，这突出了一个很大的距离，从

敌人的位置需要达到重要的安全。GWOT，全球

反恐战争；医疗，医疗后送；NPA，同行 敌手

图2。

乌克兰地图。俄罗斯军队已经袭击了医院和医疗中心 该设施位于俄罗斯-乌克兰地区以西约400公里处

边界俄罗斯的导弹袭击也发生在距离阿富汗地区25公里的范围内 波兰和乌克兰边境，这意味着几乎任何地点

乌克兰就在俄罗斯的能力范围内。图像修改从谷歌地球。

在前线进行输血 乌克兰

GSMSG团队的外科医生帮助将全血使用纳入其中

2022年4月在乌克兰发生的冲突。到达的病人的人数 在UKRSOF的前锋手术团队，已经出血

休克率估计为25%。另外还有15%到20%的存活者和患者

到达第一个医疗护理点的受伤士兵需要一个

输血乌克兰的外科医生有时会做一些接近的手术 在距离前线0.5公里的地方是第一个收到伤亡的 战场。UKRSOF的外科医生引用了长期治疗的困难 存储是维护任何可用存储的最大障碍

血液制品运行制冷储存的发电机 血液制品在前方手术部位长时间

时间可能会危及安全。除了限制了自己的能力之外

储存全血或血液制品时，经常缺乏电力 禁止用液体加热器解冻冷冻血液制品。 前锋手术团队的供应线经常出现

俄罗斯人的进攻，削弱了他们补充血液供应的能力

产品输血。还有其他的生成策略

容易获得的全血输血，如护林员O低

滴度/步行血库，需要一个庞大、稳定的供者 水池21、22然而，目前的伤亡率，部队的搬迁， 或根据在乌克兰的行动速度重组单位

排除了执行这些策略的能力。实现将

需要对乌克兰军队进行更广泛的组织演变。

更多的伤害

在乌克兰的冲突中，人们使用了专门制造的弹药 俄罗斯的工业规模和持续的火箭和炮火轰炸。

火力的增加转化了伤害负担的增加。

乌克兰医生分享的统计数据表明，超过

70%的乌克兰战斗伤亡是由火炮和火箭弹造成的 来自俄罗斯军队的炮火，这已经导致了重大的

多器官系统的多发性创伤。相比之下，在最近的一次研究中 非npa冲突，士兵在胸部和

如果伴随着四肢的损伤，腹腔可以存活下来

而身体的其他部分都是有限的。在乌克兰，这是俄罗斯的武器

给更多的士兵造成了更多毁灭性的伤害 任何给定的攻击。在一项对100例接受

乌克兰军事外科医生在前线5公里内进行手术 这样的受害者的平均受伤严重程度得分超过36

炮兵和火箭攻击。常见的损伤机制包括 多处高速穿透伤、气压损伤和钝器伤

爆炸中投掷造成的伤害，以及大脑创伤

伤害GWOT中的一个简易爆炸装置甚至一连串的简易爆炸装置受到影响

一般来说，患者较少，对其他人造成的伤害也较轻 除了直接触发简易爆炸装置的人)，而不是NPA火箭 或者是炮火的密集攻击，它会产生数十次爆炸

更大的面积，导致同时发生，多用途的情况。它是 估计有5%到10%的乌克兰士兵被部署到战区

的行动将会在行动中受伤或死亡。在

在GWOT，大约有7000人死亡，32000人受伤 总共部署了200到300万美国人员，造成伤亡

发病率为1.3%至2%。24因此，在这个和未来的NPA的死亡率 冲突可能是GWOT的5倍(尽管是乌克兰人

死亡率是基于公开可获得的原始估计数

此时的信息还没有根据受伤的严重程度进行调整，

机制等）。总体上，制定医疗后送计划，延长现场时间 护理和由治疗医务人员计划的其他干预措施

是否需要预测大量的多发性创伤，明显更多的患者

而单个病人所需的资源将是 明显更大。

UKRSOF的外科医生报告说接受了几个病人

同时还伴有多种潜在的致命伤害。病人经常 之前需要采取多次紧急损害控制干预措施

临床医生可以开始照顾下一个病人。在3周的时间内 随着持续的炮火袭击，一名乌克兰人

外科医生治疗了200多名患者，其中36人接受了治疗

剖腹手术和20例行了开胸手术。腹部穿透 而胸部的伤口发生在防弹衣钢板的外侧

大约60%的病例，30%的病例不如防弹衣。

据估计，10%的人有材料穿透了他们的防弹甲 或者他们没有穿防弹衣。创伤性穿透伤

这个头骨几乎所有人都是致命的，并得到了期待中的治疗。

胸部穿透性创伤的发生率明显较高

这与NPA的冲突比在GWOT。大多数士兵在 目前乌克兰战争有前后面板装甲以及

头盔在战壕中，士兵一般

面朝前，遮住他们的头。然而，这就留下了横向 身体容易受伤的各个方面。使用标准中心质量

前后板护甲，保护重要的器官

“盒子”可能不足以拯救生命时，弹道材料是 来自于一个横向的轨迹。虽然有美国的防弹衣 系统确实提供了更彻底的外侧和腹部保护

侧面护甲和弹道材料

弹道炮弹，这样的设备是非常重的和 笨重的

气压损伤和创伤性脑 伤害

爆炸损伤也有气压创伤的影响，并可能导致钝器创伤 如果爆炸导致受害者被扔出去或大型物体被投掷

向受害者发射。因此，创伤性脑损伤（tbi） 在与NPA的冲突中可能会更大。在GWOT期间， 单次简易爆炸装置持续的tbi发生率显著

爆炸这些爆炸的震荡效应一直很好

备有证明文件的9%到28%的服役人员经历过a

GWOT期间的创伤性脑损伤。这是在一个罕见的现代美军实例中 美国在伊拉克的阿萨德基地遭遇了npa级别的武器装备

在2020年1月8日被伊朗的弹道导弹击中

士兵遭受tbi。26.在乌克兰冲突中，脑震荡受伤

并且在几乎所有的患者中都有相关的投诉

遇到反对派的火箭或炮火，尽管经常发生

他们被其他的伤口蒙上了阴影。我们也知道 如果患者持续连续脑震荡或脑外伤，长期

其影响的破坏性明显要大得多。27.在战斗的情况下 对于NPA，tbi很可能会比

在GWOT中所经历的事情。加强和埋葬防御措施 使人员不暴露于爆炸影响

帮助减轻这些伤害；然而，医疗计划应该

继续针对预防性、保护性和治疗性 对抗tbi的措施。

医疗疏散

在GWOT期间，美军通常占据战场的主导地位 迅速建立，威胁在医疗前普遍被清除

疏散可能会发生，除了罕见的孤立事件

例子与乌克兰国防部进行的每次讨论均为28、29次 同行，在撰写本文时，有最小的能力

乌克兰空军进行任何类型的持续空中行动

俄罗斯军队，其中包括空中医疗后送（医疗直升机） 从前线位置或邻近地区的信封内

俄罗斯防空火力。30大奖章由地面部队也经常使用 遭到了俄罗斯军队的攻击。美国应该这样认为

先进、精确和非常远程的武器系统将很容易实现

可用于未来的npa。因此，更安全的地方就被远离了 战斗将需要疏散能力，无论是通过空中，地面，

或者海，可能需要从前线移动数百公里 在伤亡之前，医疗平台本身是安全的

从NPA火。

这也意味着前沿医疗团队将需要的能力

提供长期的现场护理，更多的损伤控制复苏，以及

甚至对更多的病人进行了多次损伤控制手术 在他们离开前线地区之前。乌克尔索夫

驻扎在战斗前线附近的外科医生通常只能做到 将病人从受伤点转移到接近500米的地方

进入硬化的位置，让手术团队可以进行手术和持有 病人被延长了一段时间。这种情况偶尔会发生

在俄罗斯持续的火炮和火箭火力下。未来的美国服务 在战斗中受伤的成员可能因此无法到达

明确的护理，直到几天后，和医务人员提供护理 肯定会有危险的地方。

目前美国国防部的协议和临床实践

指导方针为较小的前锋手术团队做好了准备

对2-4名手术患者进行手术，其中3-8名患者为16-72名 小时没有补给。此外，他们应该能够打包

他们的设备将在1小时内搬迁。据估计，基于

UKRSOF在与俄罗斯的战斗经验，这样的团队应该是 准备在48小时内进行10次损伤控制操作并保持不变

多达15名危重患者相同时间没有

再供给这大约是一个中等大小的重症监护病房的大小 大小的美国医院。扩大一个前锋团队的能力将会使

它的流动性更低，搬迁也更困难。这是显而易见的 在需要更大的前沿医疗能力和

根据需要迅速迁移到新的更安全的地点的能力 与不断移动的前线保持节奏。

尽管这明显违反了来自日内瓦的国际法

在《公约》中，俄罗斯军队是专门针对救护车和救护车的

医疗设施。据乌克兰危机媒体中心报道，

大约有1100家医疗保健设施被损坏或被损坏 从冲突一开始就被摧毁了。32前瞻性医疗

因此，像战斗支援医院这样的设施可能需要 完全位于地下。这可能意味着重要的

投资于快速隧道和土方运输设备

需要，目前没有一个存在于一个可以 迅速部署到战场上的。目前的实践

带有混凝土墙和土墙的结构仍将离开

它们很容易受到垂直攻击。点防御的快速发展

系统来自现有的反火箭、火炮、迫击炮（C-RAM）或 以色列的铁穹顶，也将是保护的必要组成部分

关键的军事医疗基础设施。如果水上疏散是

考虑到，未来的美国军队需要认识到海上船只的报价

非常容易成为未来npa的目标。一个潜在的解决方案是建立起来 “利利垫 ”医疗设施在任何邻近的陆地上，如美国

太平洋军队在第二次世界大战中，在马歇尔号上建造了机场

以及马里亚纳群岛在前往日本的途中。33

医疗直升机的行动也更有可能受到挑战

在与NPA发生冲突时的沟通。在过去的战争中，美国的工作人员 能够与医疗单位沟通协调

受伤人员的移动。34.反对派力量的做法 干扰美军用于通信的电子频谱

将在未来的NPA冲突中损害这些过程。在乌克兰， 响应的医务人员和接收医疗设施

经常没有事先通知的性质或范围

由于害怕俄罗斯人，从前线传来的病人受伤了 拦截通信，然后攻击攻击的位置

伤亡收集点。未来美国医疗队的一种方法 准备失去沟通将强调不通知

训练和模拟中的场景。在民用领域，不另行通知或 当病人被运送到

警察或私家车。所有的临床医生都可以从中受益

练习这些情况。我们有理由相信这些人 战时的通信障碍也将扩展到控制和控制 指挥整个业务领域的医疗供应链。

经过几十年的冲突和以前的全面战争经验，就像这样

正如第二次世界大战，以及地区冲突，如越南，导致了 对美国军事医疗系统的巨大压力，美国已经发展起来

适当、统一地分配医疗资产和医疗用品的系统

到最需要的领域。面对未来的民族军冲突，盟军 命令和控制的层次结构可能会被切断

安全原因或由于NPA中断。这一点也必须得到解决 在与NPA的冲突中，尽管它并不是一个全新的

担心

外科干部

每年，有近1000名外科医生从住院医师培训中毕业 他会以某种能力做普通外科手术。38目前有

在美国有2.5万名活跃的普通外科医生，其中约有4130人 是创伤外科医生。这可以作为一个足够的池

有潜在的合格的人，可以提供合格的创伤

在一场有大规模动员的战争中提供外科手术服务。然而，即使这样

许多合格的外科医生，美国军方很难维持一个 已经有了一群精通损伤控制手术的外科医生

并能够立即部署到前线战区。

外科专家，包括胸外科医生，神经外科医生， 骨科外科医生，口腔颌面外科医生，

耳鼻喉科医生、泌尿科医生、血管外科医生等，都需要做 提供全面的战时护理。不幸的是，对于一个像

乌克兰——或者任何像俄罗斯这样面临反对派的国家——实际上是如此

他们不可能有足够的合格的外科医生。它是 很难确定乌克兰外科医生的确切人数。数据 《柳叶刀》全球外科委员会于2014年报道

乌克兰每10万人中有87名外科医生，但没有描述这个数字 进一步按专业或活跃状态划分。由于短缺，任何

在乌克兰的执业外科医生，无论接受的培训或培训范围如何 实践中，可带来战斗伤亡病人来管理

他们的能力。美国外科医生学会（ACS）创建了这个 诸如军事临床准备课程“M-

课程“教授基本的损伤控制手术，损伤控制 复苏和战时紧急行动来帮助填补这一空白。 ACS还与GSMSG合作，提供专家外科医生从

从美国到乌克兰，与东道国的外科医生一起工作 提供特定战斗创伤主题的教育和培训，比如

烧伤手术，整形手术，甚至是生物战和化学战。

GSMSG与任何东道国合作的主要目标都是迅速合作 将相关技能和知识转移给合作力量外科医生

和医疗专业人员。截至2022年12月，GSMSG已经持有 为650多名乌克兰与会者和居民提供的培训课程

医生和参加实践培训超过300人

手术室病例与乌克兰外科医生自开始 战争

总之，美国作战医疗系统的几个领域需要改变 应对NPA的威胁。应该注意的是，在乌克兰

目前还没有类似于美国使用的创伤登记处

美国国防部在伊拉克和阿富汗的战争。数据 本文介绍的是基于GSMSG团队的个人经验

成员和第一手报告。建立一个有效的注册表

需要稳健和可靠的数据捕获来提供适当的规划 以及对对抗NPA的反应以及回顾性分析。

像GSMSG这样的非政府组织可以成为

在这类冲突中的重要资产，因为它们可以提供有价值的资产

训练，战斗护理，和经验为东道国没有 通过直接涉及外国政府或

军人此外，它们还可以是有价值的信息的来源

在美国国防部正式介入并提供帮助之后 它为冲突做准备。

总之，这里列出了从经验中吸取的教训

GSMSG和来自乌克兰特别行动组织的合作医生

在乌克兰对俄罗斯作战一年后的军队。的注意事项

强调了今后针对国家援助机构作战行动中的医疗护理。

1.

NPA冲突中的伤害 a.

目前的美国军用防弹衣可能不足以对付NPA

带有弹道组件的武器库，可以击中侧面，上面，或 低于标准问题的护甲板从多个角度由于

更多的精确影响弹药。 b

.

创伤性脑损伤和创伤性脑损伤将更为普遍 能够准确地提供大量更具破坏性的武器库

火 c.

NPA武器库将能够造成严重的多系统创伤 提供给更多的美国人员。

2.

为NPA冲突中的受伤者提供护理 a.

医疗设施并不是提供护理的安全区域，即使它们是这样的 距离地面战斗线数百公里。

b.

充分提供救生护理所需的资源将是远远的 比美国过去分配的钱要多。

c.

空中、地面和海上的医疗后送将是实际的 由于NPA的远程和精确的射击能力，不可能 军火库；前锋手术团队应该建立在硬化

可能在地下，能够抵抗直接攻击

由NPA弹药。 3.

准备和培训针对NPA冲突的美国医疗队 a.

美国工作人员的前沿医疗/外科能力将需要具备 能够同时处理更多的伤亡人员。

b.

长期的现场护理应成为医疗培训的常规组成部分 课程，因为疏散可能会延迟或不可能

争执 c

.

在未来的NPA冲突中，通信可能是有限的或 由于国家PA干扰或操作安全而不存在

原因，防止提前通知伤亡人员到达，这是这样一种情况 应定期练习(无通知的伤亡负荷与广泛

高保真度、基于情境的培训)。 4.

美国军事医疗系统的系统级准备和

未来NPA冲突的结构 a.

由于NPA对手的电子干扰，健壮和冗余 对医疗资产的指挥和控制应能够被委托 进一步进入这个领域。

b

.

需要培养合格和有能力的外科医生的干部，以便

他们已经准备好了，已经有能力了，并且愿意部署到一个前进的地点 未来的NPA冲突。

c

.

具有在损伤控制手术和复苏方面的专业知识的外科医生 是有限的，但这个差距也可以通过专业培训来填补，吗 通过像GSMSG这样的小组，或者通过像

由ACS提供的m课程。 d .

国家爱国者可能会无视反对攻击医疗机构的国际法 资源、医疗后送平台和基础设施。

e.

需要实施一个像美国联合创伤登记处这样的数据库 为了改善对俄罗斯战争的进程，但美国可以

将来实现其已经建立的数据采集协议 NPA冲突。

![](/media/202412//1733466121.124469.png)

![](/media/202412//1733466121.1382651.png)Putting Medical Boots on the Ground: Lessons from the War in Ukraine and Applications for Future Conflict with Near-Peer Adversaries

**THE GLOBAL WAR ON TERROR VS CONFLICT WITH A NEAR-PEER**

**ADVERSARY**

Global War on Terror: the threat

During the GWOT, US and allied forces’ injuries were generally from

small-caliber firearms, improvised explosive devices (IEDs), and

indirect fire from short-range mortars and rockets.[3](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R3) There were an

estimated 7,076 US deaths and 53,337 US wounded during the course of those 20 years.[4](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R4) Explosive mechanisms of injury made up the largest

portion of combat wounds in the GWOT, accounting for approximately 79% of battlefield injuries. During nearly any attack by insurgent forces, US forces quickly achieved battlespace dominance and were able to

evacuate casualties under the umbrella of superior ground fire or close air support.[5](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R5) In general,the threats during the GWOT were limited in duration and scope.[6](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R6)-[8](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R8) It is also well-documented that quality medical care could be rendered quickly and safely on or near the battlefield.

Because of air-evacuation capabilities, patients could be brought

quickly to treatment facilities. The further medical assets were removed from the conflict, the safer they were, even if they were still in the

combat theater of operations.[9](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R9) Finally, damage control resuscitation

had been modified to include early use of fresh whole blood and

improved protocols, which reduced the overall amount of blood product needed to save lives.[10](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R10)-[12](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R12)

Near-peer adversary threat: greater lethality

IEDs caused significant casualties in the GWOT.[13](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R13) They could injure multiple personnel at once and even disable vehicles. Compared with insurgent/terrorist forces,NPAs have much heavier and longer-range weaponry, with a resultant increase in morbidity and mortality among combat casualties. Although it is possible to arrange IEDs to provide successive blasts to increase their lethality, these configurations were infrequently employed in the GWOT. In Ukraine, Russian forces have used modern portable antitank guided missiles with advanced dual

shaped charge or thermobaric warheads or thermobaric rocket artillery barrage fire. These thermobaric weapons cause blunt and penetrating wounds as well as massive thermal injuries.[14](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R14) A recent incident using this weapon claimed 12 immediate fatalities from victims who were

within 20 meters of the impact point. A casualty 60 meters away from

the point of impact suffered 80% total body surface area burns that proved lethal within 72 hours despite medical evacuation and

resuscitation attempts.

Russian use of incendiary munitions causes significant deep burn

injuries, organophosphate poisoning, and other toxic effects from the vapors associated with the burning substances.[15](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R15) Care of burn

casualties imposes a significant logistical and medical burden because of the complexity of care and the extensive resuscitation required. This underscores the need to plan for significant thermal/burn injuries in

future combat.

Modern antitank guided missiles that have been used widely by Russia have a nearly +75% fatality rate when employed against personnel or lightly armored vehicles, because they are intended for use against

tanks or bunkers. US military personnel encountered these weapons

infrequently during the GWOT.[16](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R16) They appear to be a much more

frequent occurrence in this NPA conflict.[17](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R17) The injuries sustained have been devastating, and survival rates are significantly lower than those from nondirectional blast injuries such as artillery and mortars.[13](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R13)

Additionally, Russian forces in this conflict have been firing nearly 60,000 artillery rounds a day. This represents a volume of fire that US forces have not seen since WorldWar II.

In Ukraine, Russian forces often used area denial munitions, such as

antitank and antipersonnel mines. These munitions are built using

standardized, consistent construction completed on a much larger

scale. As such,they are more available, operationally reliable, effective, and deployable. IEDs used in the GWOT were, by definition, improvised and thus had questionable reliability. They often comprised an array of available explosive devices and were used with much less density of

devices in a given area when compared with broad NPA employment.

Safety of medical assets on the battlefield

The ability to quickly evacuate patients and the safety of responding medical teams are compromised because of better NPA weaponry. The ability of the Russian forces to strike accurately well beyond the front line with long-range weapons such as cruise missiles or drones means that the threat to injured personnel only subsides once a patient is far removed from the conflict theater (Fig. [1](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/figure/F1/)). In Ukraine, hospitals and medical facilities were targeted and hit as far west as Zhytomyr, which is approximately 400 km west of the Russian border[18](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R18) (Fig. [2](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/figure/F2/)).

Additionally, Russian missile strikes have occurred within 25 km of the Polish border with Ukraine, meaning that Russian weapons could strike medical centers in any Ukrainian city.[19](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R19) In comparison, in the GWOT, the insurgent arsenal had a reach of approximately 20 km. When

applied to possible future conflicts with NPAs, it is likely that the

enemy’s arsenal would be able to reach hundreds of kilometers from the frontline. For example, the Chinese CJ-10 cruise missile is capable of

carrying a 1,000-lb warhead more than 1,500 km.[20](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R20) If an operation is to be performed in a forward environment, patients will need to be treated while under the threat of attack in hardened and protected facilities

until the patients are removed entirely from the theater of operations.

[Figure 1.](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/figure/F1/)

Linear effect of distance. This figure highlights the relationship of

relative safety of MEDEVAC units as distance from the enemy position changes. The blue line shows the relationship in the GWOT, which

highlights the rapid increase in safety with a small amount of distance from the enemy position. The red line shows the relationship in NPA conflict, which highlights that a large amount of distance from the

enemy position is needed to achieve significant safety. GWOT, Global War on Terror; MEDEVAC, medical evacuation; NPA, near-peer

adversary.

[Figure 2.](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/figure/F2/)

Map of Ukraine. Russian forces have struck hospitals and medical

facilities in Zhytomyr, about 400 km west of the Russian-Ukrainian border. Russian missile strikes have also occurred within 25 km of the Polish-Ukrainian border, which means nearly any location within

Ukraine is within Russia’s reach. Image modified from Google Earth.

Transfusion at the frontline in Ukraine

Surgeons on the GSMSG teams helped incorporate whole blood use into the conflict in Ukraine in April 2022. The number of patients who arrive at a UKRSOF forward surgical team alive and already in hemorrhagic

shock is estimated at 25%. An additional 15% to 20% of alive and

injured soldiers arriving at the first point of medical care needed a

blood transfusion. Ukrainian surgeons sometimes operating as close as 0.5 km from the frontline are the first to receive casualties from the

battlefield. UKRSOF surgeons cite that difficulties with long-term

storage pose the biggest obstacle to maintaining stores of any available blood products. Running power generators for refrigerating stored

blood products at the forward surgical sites for extended periods of

time could compromise security. In addition to limiting the ability to

store whole blood or blood products, the lack of electrical power often prohibits thawing available frozen blood products with fluid warmers. Supply lines to the forward surgical teams routinely come under

Russian attack, impairing the ability to replenish supplies of blood

products for transfusion. There are additional strategies for generating readily available whole blood for transfusion, such as the Ranger O Low Titer/Walking Blood Bank, which require a large, stable donor

pool.[21](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R21),[22](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R22) However, the current rate of casualties, relocation of units, or reorganization of units given the operational tempo in Ukraine

precludes the ability to execute these strategies. Implementation would require broader organizational evolution of the Ukrainian military.

Greater number of injuries

The Ukrainian conflict has seen the use of purpose-built munitions on an industrial scale and sustained rocket and artillery barrages by Russia. This increase in firepower has translated to an increased injury burden. Statistics shared by Ukrainian physicians demonstrate that more than 70% of all Ukrainian combat casualties are due to artillery and rocket

barrages from Russian forces, which has resulted insignificant

polytrauma to multiple organ systems. By comparison, in most recent non-NPA conflicts, soldiers who sustained injuries to the thoracic and abdominal cavities could survive if concomitant injuries to extremities and the rest of the body were limited.[23](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R23) In Ukraine, Russia’s weapons have led to more devastating injuries to a larger number of soldiers in any given attack. In a retrospective analysis of 100 patients treated by Ukrainian military surgeons operating within 5 km of the frontline, the average Injury Severity Scores exceeded 36 in victims of such barrage

artillery and rocket attacks. Common mechanisms of injury include

multiple high-velocity penetrating injuries, barotrauma, and blunt

injuries from being thrown during the explosion, and traumatic brain

injuries. A single IED or even a chain of IEDs in the GWOT affected

fewer patients, in general, and caused less severe injury (to others

besides the person who directly triggered the IEDs) than an NPA rocket or artillery barrage, which produce dozens of explosions across a much larger area,leading to simultaneous, multicasualty situations. It is

estimated that 5% to 10% of Ukrainian soldiers deployed to the theater of operations will be either wounded or killed in action. During the

GWOT, there had been approximately 7,000 deaths and 32,000 wounded in a total of 2 to 3 million deployed US personnel, for a casualty

incidence of 1.3% to 2%.[24](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R24) Thus, mortality rates in this and future NPA conflicts maybe 5 times greater than in the GWOT (although Ukrainian mortality rates are raw estimates based on publicly available

information at this time and not adjusted for injury severity,

mechanism, etc.). Overall, medical evacuation planning, prolonged field care, and other interventions planned by treating medical personnel

will need to anticipate massive polytrauma, significantly more patients at a time, and the resources required for a single patient will be

significantly greater.

The UKRSOF surgeons reported receiving several patients

simultaneously with multiple potentially lethal injuries. Patients often require multiple emergent damage control interventions before

clinicians can begin to care for the next patient. During a 3-week period with sustained incoming artillery barrage fire, a single Ukrainian

surgeon treated more than 200 patients, of whom 36 underwent

laparotomies and 20 underwent thoracotomies. Penetrating abdominal and thoracic wounds occurred lateral to body armor plates in

approximately 60% of cases and inferior to body armor in 30% of cases. An estimated 10% either had material penetrate their body armor plates or they were not wearing body armor. Traumatic penetrating injuries to the skull were nearly universally fatal and were managed expectantly.

The incidence of penetrating thoracic trauma is significantly higher in this conflict with an NPA than in the GWOT. Most soldiers in the

current war in Ukraine have front and rear panel armor as well as a

helmet. With incoming artillery rounds in a trench, soldiers generally face forward and cover their heads. However, this leaves the lateral

aspects of the body vulnerable to injury. Use of standard center mass front and rear plate armor that protects the vital organs within “the

box” may not be sufficient to save lives when ballistic material is

coming from a lateral trajectory. Although available US body armor

systems do offer more thorough lateral and abdominal protection with

side armor plates and ballistic material that can protect lateral trajectory projectiles, such equipment is extremely heavy and cumbersome.

Barotrauma and traumatic brain injury

Blast injuries also have barotrauma effects and can cause blunt trauma if the explosion results in the victim being thrown or large objects being launched at the victim. Consequently, traumatic brain injuries (TBIs)

will likely be greater in conflicts against an NPA. During the GWOT,

there was a significant incidence of TBIs sustained from single IED

detonations. The concussive effects of these blasts have been well

documented. Between 9% and 28% of servicemembers experienced a

TBI during the GWOT.[25](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R25) In a rare modern instance of US forces

encountering NPA-level weaponry, the US Al-Asad base in Iraq was

struck by Iranian ballistic missiles on January 8, 2020, and 109 US

soldiers suffered TBIs.[26](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R26) In the Ukraine conflict, concussion injuries

and related complaints were noted in nearly all instances of patient

encounters with opposition rocket or artillery fire, although oftentimes they were overshadowed by other wounds or injuries. We also know that if patients sustain successive concussions or TBIs, the long-lasting

effects are significantly more devastating.[27](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R27) In a combat situation

against an NPA, it is likely that TBIs will be far more prevalent than

what was experienced in the GWOT. Reinforcing and burying defensive positions so that personnel are not as exposed to the blast effects may

help mitigate these injuries; however, medical planning should continue to be directed at prophylactic, protective, and treatment measures to combat TBIs.

Medical evacuation

During the GWOT, battlespace dominance by US forces was usually

quickly established, and threats were generally cleared before medical evacuation could occur, with the exception of rare isolated

instances.[28](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R28),[29](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R29) Per discussions with Ukrainian Ministry of Defense

counterparts, as of this writing, there is minimal ability for the

Ukrainian Air Force to fly any type of sustained air operations against Russian forces, which includes airborne medical evacuation (MEDEVAC) from frontline positions or areas adjacent within the envelope of

Russian antiaircraft fire.[30](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R30) MEDEVAC by ground forces also routinely

comes under attack by Russian forces. The US should assume that

advanced, accurate, and very long-range weapon systems will be readily available to future NPAs. As such, the safety of being further away from combat will require that evacuation capabilities, whether by air, ground, or sea, may need to move hundreds of kilometers from the frontline

before the casualty and the MEDEVAC platform itself is actually safe from NPA fire.

This also means forward medical teams will need the capability of

providing prolonged field care, more damage control resuscitation, and even multiple damage control surgeries on a larger number of patients before they can be moved away from the frontline area. UKRSOF

surgeons stationed adjacent to the frontline of combat often could only move patients from the point of injury to locations as close as 500 m

into hardened locations where a surgical team can operate and hold the patient for an extended period of time. This was occasionally done

under ongoing Russian artillery and rocket fire. Future US service

members who are injured in combat may consequently not reach

definitive care until days later, and medical personnel providing care will definitely be in harm’s way.

Current US Department of Defense protocols and clinical practice

guidelines prepare for smaller forward surgical teams to be able to

operate on 2 to 4 surgical patients and hold 3 to 8 patients for 16 to 72 hours without resupply.[31](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R31) Additionally, they should be able to pack

their equipment within 1 hour to relocate. It is estimated that, based on UKRSOF experience in combat with Russia, such teams should be

prepared to perform 10 damage control operations in 48 hours and hold up to 15 critically ill patients for the same amount of time without

resupply. This is about the size of an intensive care unit in a medium- sized US hospital. Expanding a forward team’s capabilities would make it less mobile and more difficult to relocate. This poses an obvious

paradox between the need for greater forward medical capabilities and the ability to relocate rapidly to new safer locations as needed and to maintain pace with a constantly moving frontline.

Despite clearly violating international laws from the Geneva

Convention, Russian forces are specifically targeting ambulances and healthcare facilities. According to the Ukraine Crisis Media Center,

approximately 1,100 healthcare facilities have either been damaged or destroyed since the beginning of the conflict.[32](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R32) Forward medical

facilities, like a combat support hospital, therefore, may need to be

positioned entirely underground. That may mean significant

investments in rapid tunneling and earth-moving type of equipment

are needed, none of which currently exists in a capability that can be

deployed rapidly to a battlefield. The current practice of surrounding

the structures with concrete walls and earth barriers will still leave

them vulnerable to vertical attack. Rapid advances in point defense

systems from the existing Counter-Rocket, Artillery, Mortar (C-RAM) or the Israeli Iron Dome, will also be a necessary component of protecting critical military medical infrastructure. If waterborne evacuation is

considered,future US forces need to recognize that ships at sea offer

very easy targets for future NPAs. A potential solution is to establish

“lillypad” medical installations on any adjacent land masses, as the US Pacific forces did in WorldWar II, constructing airfields on the Marshall and Mariana Islands en route to Japan.[33](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R33)

MEDEVAC operations are also more likely to be challenged by a lack of communication during conflict with an NPA. In past wars, US personnel

were able to communicate with MEDEVAC units to coordinate

movement of injured personnel.[34](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R34) The practices of opposition forces

jamming the electronic spectrum used by US forces to communicate

will impair these processes during future NPA conflicts. In Ukraine,

responding medical personnel and receiving medical installations

frequently have no advance notice as to the nature or extent of the

injuries of the incoming patients from the frontline for fear of Russians intercepting the communications and then attacking the location of the casualty collection point. One way for future US medical teams to

prepare for loss of communication will be to emphasize no-notice

scenarios in training and simulation. In the civilian arena, no-notice or limited-notice scenarios may occur when patients are transported by

police officers or private vehicle.[35](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R35)-[37](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R37) All clinicians can benefit from practicing these situations. There is reason to believe that these

wartime communication obstacles would also extend to controlling and commanding medical supply chains over the entire area of operations. Through decades of conflict and previous experience in total war, such as WorldWar II, and regional conflicts, such as Vietnam, that placed

massive stress on US military medical systems, the US has developed systems to properly and uniformly allocate medical assets and supplies to areas of greatest need. In the face of future NPA conflicts, the allied command-and-control hierarchy maybe cut off either for operational security reasons or due to NPA disruption. This also must be addressed in a conflict against an NPA, even though it is not an entirely new

concern.

Surgical cadre

Each year, nearly 1,000 surgeons who graduate from residency training will practice general surgery in some capacity.[38](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R38) There are currently

25,000 active general surgeons in the US, approximately 4,130 of whom are trauma surgeons.[39](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R39),[40](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R40) This could serve as a sufficient pool of

potentially qualified individuals who can provide competent trauma

surgery services in a war with mass mobilization. Yet, even with this

many qualified surgeons, it is difficult for the US military to maintain a ready pool of surgeons who are well versed in damage control surgery and able to deploy to a frontline combat area at a moment’s notice.

Surgical specialists, including thoracic surgeons, neurosurgeons, orthopaedic surgeons, oral and maxillofacial surgeons,

otolaryngologists, urologists, vascular surgeons, etc., are needed to

provide comprehensive wartime care. Unfortunately, for a country like Ukraine—or any country facing opposition like Russia—it is practically impossible that they will have enough qualified surgeons on hand. It is difficult to determine the exact number of Ukrainian surgeons. Data

collected by the Lancet Commission on Global Surgery in 2014 reported 87 surgeons in Ukraine per 100,000 but did not delineate this number further by specialty or active status.[41](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R41),[42](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10344429/#R42) Because of the shortage, any

practicing surgeon in Ukraine, regardless of training or scope of

practice,maybe brought combat casualty patients to manage to the

best of their ability. The American College of Surgeons (ACS) created

programs such as the Military Clinical Readiness Curriculum “M-

Course” to teach the basics of damage control surgery, damage control resuscitation, and emergency wartime operation to help fill this gap.

The ACS also collaborated with GSMSG to provide expert surgeons from the US to Ukraine to work alongside host nation surgeons and to

provide education and training in combat trauma-specific topics like

burn surgery, plastic surgery, and even biological and chemical warfare. GSMSG’s primary goal in working with any host nation is to rapidly

transfer relevant skills and knowledge to the partner-force surgeons and medical professionals. As of December 2022, GSMSG has held

training sessions for more than 650 Ukrainian attending and resident physicians and participated in hands-on training in more than 300

operating room cases with Ukrainian surgeons since the start of the

war.

In all, several areas of the US combat medical system need to change in response to the threat of an NPA. It should be noted that in Ukraine

there is currently no trauma registry similar to the one used by the US

Department of Defense for its wars in Iraq and Afghanistan. The data

presented here are based on personal experience of GSMSG team

members and first-hand reports. Establishing an effective registry with robust and reliable data capture is needed to provide proper planning and reaction to combat against an NPA as well as retrospective analysis.

Properly staffed nongovernment organizations like GSMSG can be an important asset in such conflicts because they can provide valuable

training,combat care, and experience for host nations without

escalating the conflict by directly involving foreign governments or

militaries. Additionally, they can be a source of valuable information after the official involvement of the US Department of Defense to help it prepare for conflict.

In summary, listed here are the lessons learned from the experiences of GSMSG and partner physicians from the Ukrainian Special Operations Forces from 1 year of war against Russia in Ukraine. Considerations for future medical care in combat operations against NPAs are highlighted.

1.

Injury in NPA conflict

a.

Current US military body armor will likely be insufficient against NPA

arsenals with ballistic components that can hit laterally, above, or below standard issue armor plates from multiple angles due to the larger number of accurately impacting munitions.

b.

Concussive injury and TBI will be far more prevalent when facing NPA arsenals that can accurately deliver large volumes of more devastating fire.

c.

NPA arsenals will be capable of causing significant multisystem trauma to far greater numbers of US personnel.

2.

Providing care for injured in NPA conflict

a.

Medical facilities are not safe areas to provide care, even if they are

hundreds of kilometers from the line of ground fighting. b.

The resources needed to adequately provide lifesaving care will be far greater than what the US has allocated for in the past.

c.

Air, ground, and sea–based medical evacuation will be practically

impossible due to very long range and accurate fire capabilities of NPA arsenals; forward surgical teams should be established in hardened

structures, possibly underground, capable of withstanding direct attack by NPA munitions.

3.

Preparation and training of US medical teams for NPA conflict

a.

Forward medical/surgical capabilities by US personnel will need to be

able to handle more casualties simultaneously. b.

Prolonged field care should be a routine part of the medical training

curriculum, because evacuation maybe delayed or impossible in an NPA conflict.

c.

In a future NPA conflict, communications maybe limited or

nonexistent due to jamming by the NPA or for operational security

reasons, preventing advanced notice of casualty arrivals, a scenario that should be practiced regularly (no-notice casualty loads with extensive high-fidelity, situation-based training).

4.

System-level preparation of the US military medical system and structure for future NPA conflict

a.

Given electronic jamming by NPA adversaries, robust and redundant command and control of medical assets should be able to be delegated further into the field.

b.

Cadres of qualified and capable surgeons need to be developed so that they are ready, able, and willing to deploy to forward locations in a

future NPA conflict.

c.

Surgeons with expertise in damage control surgery and resuscitation are limited,but this gap maybe filled through specialty training, either in person by groups like GSMSG or remotely through programs like the M-Course provided by the ACS.

d.

NPAs may ignore international laws against attacking medical resources, medical evacuation platforms, and infrastructure.

e.

A database like the US Joint Trauma Registry needs to be implemented

for process improvement in the war against Russia, but the US could implement its already established data collection protocol in a future NPA conflict.