俄乌的可转移军事医学经验

**分析**

![](/media/202412//1733471255.2539232.png)从俄乌克兰战争中获得的可转移的军事医学教训 Timothy J霍吉特，1DN诺曼，![](/media/202412//1733471255.2626112.png)2DM鲍利2

OPENACCSS

1英国利奇菲尔德，国防医疗服 务中心，卫生局局长2伯明翰， 皇家国防医学中心，军事外科和 创伤学术系，英国

**函件**

英国皇家国防医学中心，军事外科 和创伤学术系，伯明翰，B15 2WB , 英国；david.naumann@ nhs.net

2023年4月13日收到 2023年6月5日接受

![](/media/202412//1733471255.2723544.png)©作者(s)（或其雇主(s)）2023 。在CC BY-NC条件下允许的再使 用。没有商业再利用。请参阅权 限和权限。出版的英国医学杂志

。

引用：霍奇茨TJ，诺曼DN，鲍利 DM。*英国医学杂志的健康* *电子酒吧领先*

*请包括月份。*doi:10.1136/ 军事-2023-002435

![](/media/202412//1733471255.2820404.png)

**摘要**

乌克兰战争的第一年为英国国防医疗服务部门（D MS）提供了关于其准备支持国家大规模作战的关 键教训。必须解决一些战术、临床和战略挑战。

这场战争暴露了国际人道主义法和武装冲突法在 保护前线野战医院免受蓄意攻击方面的局限性。

DMS可能需要采取诸如伪装、欺骗和分散等措施， 在有争议的环境中提供护理。在重大冲突之间对 军事医疗能力的撤资的历史趋势，被称为“沃克 倾斜 ”，代表了一种必须减轻的临床风险。即使 实现了这一目标，在大规模战争中取得的临床结 果也可能比美国在更低强度的冲突中所预期的更 糟。有效的军民合作对于大规模管理伤亡人数至 关重要。可能需要新的和可逆的运输方式，如火 车上伤亡人员的大规模移动。在全球经济短缺和 新冠肺炎后职业倦怠的情况下，需要足够和有能 力的医疗人员，因此需要进一步投资。DMS需要创 新和适应性，以利用采用外部想法、转化成功的 创新和应对复杂挑战的能力。通过解决战术弱点 , 加强临床准备，促进军民合作，并拥抱创新，

DMS将更好地装备，在未来的大规模作战中支持英 国和盟国的武装部队。

**介绍**

拿破仑 ·波拿巴认识到，当指挥官将野战医院转 移到军队前线时，他们宣布意图承担伤亡，因此 打算战斗。2022年1月，国际社会观察到，在乌克 兰北部、东部和东南部边界出现了野战医院，主 要是使用开源材料。这里有大学生的献血活动，

使用大型麻醉动物模型的俄罗斯军事医疗演习，

以及返回圣彼得堡的医疗后送链。这些意图声明 警告说战争即将来临。12022年夏天，乌克兰医疗 联盟的创始人兼首席执行官奥琳娜 ·切尔年科表 示，尽管“战争 ”在媒体和公共传播中无处不在 , 但乌克兰的医院在系统层面上对入侵没有做好

准备。

2

英国的国防医疗服务机构（DMS）和国民保健服务机 构是否已经准备好采取同等的应对措施来支持这个国 家？*2022年7月，《皇家联合服务研究所期刊》发表* *了一篇题为《你是最薄弱的环节：英国国防医疗能力* *的极限》的文章。*3 这篇文章阐明了一个“令人不安 的事实 ”：乌克兰战争凸显了冷战后30年和平红利期 间在战争中积累的军事医疗能力差距。它得出结论，

如果行动动员，重组DMS至关重要4（ “阻止俄罗斯的 侵略 ”和“防止战争 ”的任务）即将实现。现在是解 决集体医疗能力缺陷的时候了，从乌克兰战争中吸取 教训，这些教训已直接与联盟卫生局局长社区分享。 其他来自美国的人总结了乌克兰战争第一年的一些教 训。5 当前的文章讨论了最重要的战术，临床和战略 经验，适用于英国的DMS根据其卫生局局长，以及一 些减轻确定的医疗挑战。通过改进概念和学说来学习 和适应这些经验教训，将确保为未来的大规模作战做 好准备。

**战术的**

**滥用国际人道主义法和武装冲突法**

以前曾假定，一项原则（《日内瓦公约）和一个徽章 （红十字会）将在前线野战医院内的州-州冲突中提 供“保护 ”。然而，俄罗斯的行动表明事实并非如此 。早在入侵乌克兰之前，2016年大赦国际报告称，俄 罗斯和叙利亚政府军故意、有系统地针对医院和其他 医疗设施，为地面部队向阿勒颇北部推进铺平道路。 6 在这场旷日持久的冲突中，卫生工作者被迫进入地 下或进入没有标记的建筑物，为受伤的病人提供护理 。7 同样，在乌克兰，现在很明显，国际共识是对不 尊重武装冲突法或人道主义原则的交战双方的不充分 保护。2023年1月，英国驻欧洲安全与合作组织代表 团团长尼尔 ·布什大使强调，越来越多的证据表明， 俄罗斯军队在乌克兰地区控制期间在乌克兰犯下了战 争罪行。8 此外，

Hodgetts TJ等。*英国医学杂志Mil健康2023；0：1-4。*doi:10.1136/military-2023-002435 1

英国医学杂志医学健康：2023年7月3日以10.1136/military-2023-002435的形式首次出版。由客人于2023年9月14日从<http://militaryhealth.bmj.com/>下载。受版权保护。

**分析**

对乌克兰城市、平民和关键基础设施的持续袭击正在对乌克兰 人民造成持久的人道主义影响。在入侵开始的几周内，多个医 疗机构成为该政权的目标，往往造成毁灭性的后果。9 在这种 情况下，DMS可能需要更好地利用伪装、欺骗和分散手段，例 如使用地下停车场和地下室应急医院病房，为病人提供护理。 可能需要加强对军事总部内的医疗设施的防空保护。10

**受保护的地面医疗疏散**

受保护的地面医疗疏散允许战斗伤亡人员及时进行手术（包括“

损伤控制手术 ”）， 以保护生命和维持未来的功能。这是乌克兰最 早提出的优先事项要求之一，并得到了广泛的国际援助。此外，还 重新评估了长途移动大量伤亡的可逆方法，同时提供有意义的治疗 。这其中包括医院的列车。有一定程度的讽刺，承认医院火车是一 种方法首次使用后巴拉克拉瓦战役在克里米亚在1854年，后来细化 包括手术能力作为俄罗斯创新在1904年由外科医生维拉 ·格德罗茨 。1 1 多达60%的乌克兰军队伤亡人员是由火车向东向西转移的。除 了探索外科手术团队如何安装在飞机上的平行努力外，也有必要重 新探索如何在将伤员转移到数百英里的火车上使用这种能力。

**跨国伤亡行动**

乌克兰战争突出了解决跨大洲和各大洲之间的跨国伤亡监管要求的 必要性。为了管理从乌克兰到欧洲的平民伤亡分配，使用了欧盟应 急协调中心，并得到了军事战略空中资产的支持，特别是来自德国 和挪威的资产。为了管理军事伤亡再分配，使用了科布伦茨新的多 国军事协调中心。这一经验的教训是加强对北大西洋公约组织（北 约）盟军伤亡的理解。

**医疗用品（科罗瓦伊项目）和库存**

科罗瓦伊计划是为国际社会援助乌克兰并承诺提供致命和非致命援 助的倡议。该项目后来扩大到包括协调医疗物资的发放。这旨在避 免提供方面的关键差距，并避免重复工作。本质上。它的功能与“ 婚礼清单 ”相同，科罗瓦 ( к о р о в а и ) 是乌克兰婚礼烘焙的 象征性面包，被切下来分给交换礼物的客人。

2019冠状病毒病大流行表明，“及时 ”的物流不起作用，特 别是当消耗品（如个人防护设备）从一个共同的来源采购和供 应时。如果供应链上有多个国家的过度需求，或者如果供应链 被战争竞争或中断，就会有关键短缺的风险。为了应对这一挑 战，有几个关键的优先事项；首先考虑在英国国内必须生产哪 些关键设备或消耗品（ “主权能力 ”）；第二个

持有更多的股票，第三，如何将更多的库存轮换出去，用于医 疗保健，这样就不会浪费。

**临床的**

**在大规模战斗时，对临床结果的预期**

人们承认，在被称为“沃克潜水 ”的主要战役之间，对军事医疗

能力的历史上和周期性的投资下降。12 这样的衰退是在当代阿富 汗战役结束时出现的。这不仅仅是英国的一种现象，而且已经反映 在了整个北约联盟中。它解释了为什么临床结果在战争过程中得到 改善，部分是通过恢复能力，部分是通过创新，以匹配新的标志性 损伤或疾病模式。为了让人放心， 目前的欧洲战争一直是国际军事 医疗再投资的催化剂：缓解行动将推动医疗能力共同支持曲线。

不同的是，大规模作战期间的临床结果仍然比低强度冲突中 更差。乌克兰军事伤亡的粗略结果被表示为行动中死亡与行动 中受伤的比率，这些结果不如21世纪伊拉克和阿富汗冲突中的 生存更有利。然而，考虑到伤亡人数、有争议的疏散和重型武 器受伤的比例，这并不令人意外。它提醒着指挥官、政治家和 公众——包括服务人员的家属——要理解并接受未来这种冲突 的结果可能会更差。历史证实，国家生存的战争比选择的战争 承担更多的风险。但今天，无法达到的公众期望可能是维持

DMS以前对低强度冲突中的个人伤亡所提供的精细照顾。

**抗菌素耐药性**

在入侵之前，乌克兰的医院中普遍存在耐药微生物。*在一项对*

*>9000名手术患者的研究中，手术部位感染率很高（21%），报告有* *35.7%的金黄色葡萄球菌对甲氧西林耐药。*1 3 由于抗生素以前在处 方上出售，2022年8月，乌克兰卫生部实施了一项新程序，要求所 有患者在购买抗生素前必须从医生那里获得处方。然而， 由于复杂 伤口的患者持续涌入、治疗延误、实验室检测的周转时间长以及患 者的地理距离运输，为乌克兰抗菌素耐药性的一个主要问题造成了 “完美风暴 ”。1 4 如果在类似的情况下进行操作，DMS将需要做好 准备，并减轻这种风险。

**化学、生物、放射学和核（CBRN）考虑事项**

自2011年叙利亚冲突开始以来，俄罗斯政府通过军事援助和直接的 军事参与来支持叙利亚。叙利亚使用化学武器的指控（例如，2017 年4月4日汗沙林毒气袭击，据称造成90名平民死亡； 以及2018年4 月7日对杜马的氯气袭击，据称造成40至50人死亡）。核武器的幽 灵也受到了俄罗斯的公开威胁。*2022年9月，弗拉基米尔·普京表* *示：“如果我们国家的领土完整受到威胁，我们毫无疑问将利用一* *切现有手段保护俄罗斯和我们的人民。* *”这并不是虚张声势。*

*”*1 5 北约致力于开发和维护必要的化学品，

英国医学杂志医学健康：2023年7月3日以10.1136/military-2023-002435的形式首次出版。由客人于2023年9月14日从<http://militaryhealth.bmj.com/>下载。受版权保护。

**分析**

生物、辐射和核（CBRN）防御能力，包括情报、人员、设备、 政策、计划、演习和训练。这些都有效地融入了北约的威慑和 防御姿态；并承诺，社会将有必要的弹性应对CBRN威胁。此外 , 还有值得信赖的医疗对策、诊断和治疗，北约重新加强了其 CBRN政策，并在马德里举行的上次国家首脑峰会上签署。16

**战略性的** **军民合作**

文职和军事组织之间的合作将是大规模管理伤亡的核心。在和平

时期，当DMS参与远征部署时，这些部署可以依靠高收入国家的角 色2和角色3设施来进行紧急护理。在战争中，当东道国的平民人口 对紧急“战争手术 ”护理的需求同时增加时，情况可能会更加复杂 。对于战略疏散，民用航空、铁路和轮渡资产将提供必要的能力。 在抵达本国后，受伤的服务人员可能会压倒任何专门的军事医院的 能力，需要在平民医院接受治疗。这对那些不再拥有独立军事医院 的国家来说，是绝对的。因此，可以理解的是，北约军事委员会在 2022年批准的新的北约军事支持顶点概念的核心。在21世纪，英国 的战斗伤亡人员几乎只在伯明翰的角色4医院（目前的伊丽莎白女 王医院）接受治疗。由于伤亡人数比最近的冲突要高，英国可能需 要更多的医院，这需要的军民合作水平远远超过最近冲突所要求的 水平。

**医疗劳动力能力**

大规模战争的最大风险之一是一支足够强大的劳动力，这可以通 过内部审查得到很好地理解。1 7 无法控制的外部因素，包括全球 医护人员短缺、极端压力下的NHS以及19后的倦怠，加剧了这种脆 弱性。1 8 缓解措施可能是在一些职位已经文明、不富裕或删除的 领域重新投资，特别是如果这对企业基地的可部署性产生了支持的 影响。当退出门槛极低时，还需要确保“服务服务 ”至少与NHS一 样有吸引力。

**危机创新**

要想在危机中进行创新，就有必要利用自己成为优秀的“创新采用 者 ”的能力。这是一种将外部想法并迅速将其引入自己的组织的能 力。成为一个良好的采用者所需要的条件是敏捷、果断、 以结果为 中心、有政治意识、容忍风险、被授权和奖励。19 “创新转化 ” 是指创新传播到一个组织的不同部分，传播到另一个组织或在国际 上传播到一个盟友。一个例子可能是英国在乌克兰建立军事康复能 力方面的专业知识。然而，影响变化并不总是简单的，尤其是如果 是复杂的变化。为了使创新获得成功，需要在接收组织和响应性网 络中进行变革性的领导， 以此来实施和分配变革。这也将需要创新

相关和适应特定的需求，使创新被接受，对患者产生提高生活 的影响。DMS在计划大规模变化时考虑John Kotter描述的复杂 变化的八步模型。20

**结论**

弗拉基米尔 ·普京一直表示： “俄罗斯人和乌克兰人是一个民族， 一个整体 ”，是一个“古罗斯”的后代。2 1 这种对乌克兰国家地 位的否认导致了对克里米亚的非法吞并， 以及随后对乌克兰的非法 和无端入侵。现代弹药对平民人口和国家关键基础设施的毁灭性影 响揭示了“大规模战斗 ”的真正含义。英国的DMS有战术、临床和 战略经验需要学习。在无人机弹药和导弹范围内不再受保护的设施 中提取伤员和治疗的挑战是审查和修订现代战斗医疗支持的催化剂 。向乌克兰同行提供援助的原则必须与努力相匹配， 以确保DMS的 医疗能力准备加强，为英国和盟国武装部队提供有效支持。

推特账号@大卫恩诺曼

**合作者。**

**投稿者TJH设计并撰写了该手稿的初稿。**DNN和DMB提供了修订和批判性的评估。所有的作者 都同意最终的版本。作者没有宣布来自任何公共、商业或非营利部门的资助机构对这项研究 的具体资助。

**相互竞争的利益，没有人宣布。**

**患者同意发表，不适用。**

伦理批准不适用。

未委托的同行评审和同行评审；外部同行评审。

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**ORCID** **iD**

DN诺曼<http://orcid.org/0000-0003-2243-2325>

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<https://www.amnesty.org/en/latest/press-release/2016/03/syrian-and-russian-> forces-targeting-hospitals-as-a-strategy-of-war/[已于2023年1月23日访问]。

7诺曼DN，罗宾逊MW，鲍利DM，等。在围困城市的临时医院进行战争手术和输血。柳叶刀 2022；399：1299-301。

8外交、英联邦和发展办公室和尼尔 ·布什。有越来越多的证据表明俄罗斯军队犯下了战争 罪行：英国对欧安组织发表的声明。

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Hodgetts TJ等。*英国医学杂志Mil健康2023；0：1-4。*doi:10.1136/military-2023-002435 3

**分析**

2023.可用性：https://www.gov.uk/government/speeches/there-is-

mountingevidence-of-war-crimes-committed-by-russian-forces-uk-statement- to-the-osce[2023年1月23日访问]。

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帕克P，霍尔丹A，霍杰茨T。可怕的十字架。2022.提供日期：

<https://wavellroom.com/2022/07/27/dread-cross>[已于2023年1月23日访问]。 11班尼特JD。维拉·格德罗茨公主：军事外科医生、诗人和作家。BMJ

1992 ;305:1532 –4.

12 Jensen G，van Egmond T，奥滕沃尔P，等。军事平民伙伴关系：连接沃克经济衰退 的国际建议。J创伤急性护理调查报告2020；89（2S补充文件2）：S4-7。

13萨尔马诺夫公司，丹达OA，维多维琴科YP等。乌克兰基辅市医院的手术部位感染和抗菌素 耐药性。Wiad Lek 2019;72:760 –4.

14 Melwani M.战争是如何在乌克兰和其他地方传播耐药的超级细菌的。BMJ 2022;379:2731.

15狄金森P。普京的核最后通牒是为了冻结一场失败的战争而绝望的努力。

2022.可用性：https://www.atlanticcouncil.org/blogs/ukrainealert/putins-

nuclearultimatum-is-a-desperate-bid-to-freeze-a-losing-war[2023年1月23日访问]

。

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selectedLocale=en[2023年1月23日访问]。 17国防部。医疗操作的概念。2022.可用性：

<https://www.gov.uk/government/publications/medical-operating-concept>[已于2023年1 月23日访问]。

法语L，汉娜P，汉克尔C。如果我死了，他们也不在乎。”新冠肺炎期间国家卫生服务人员遭 受的基于背叛的道德伤害经历。精神创伤2022年；14：516-21岁。

19 Hodgetts BT。危机期间快速创新——冠状病毒环境的军事课程。领导人2020；4： 105-8。

科特国际公司。引导变革的8个步骤。科特的屡获殊荣的方法是经过证明的方法来产生持久的 变化。2023.可用：<https://www.kotterinc.com/methodology/8-steps/>[2023年1月23日 通过]。

21普京V。关于俄罗斯人和乌克兰人的历史团结。2021.可用： http://en。 kremlin.ru/events/president/news/66181[已于2023年1月23日访问]。

英国医学杂志医学健康：2023年7月3日以10.1136/military-2023-002435的形式首次出版。由客人于2023年9月14日从<http://militaryhealth.bmj.com/>下载。受版权保护。

4霍杰茨TJ等。*英国医学杂志Mil健康2023；0：1-4。*doi:10.1136/military-2023-002435

**Analysis**

![](/media/202412//1733471268.9161348.png)Transferable military medical lessons from the Russo- Ukraine war

OPEN ACCESS

Timothy J Hodgetts,1 DN Naumann [![](/media/202412//1733471268.9237733.png)](http://orcid.org/0000-0003-2243-2325) ,2 DM Bowley2

1Surgeon General, Defence

Medical Services, Lichfield, UK 2Academic Department of

Military Surgery and Trauma, Royal Centre for Defence

Medicine, Birmingham, UK

**Correspondence to**

Lt Col DN Naumann, Academic Department of Military Surgery and Trauma, Royal Centre for

Defence Medicine, Birmingham, B15 2WB, UK; david.naumann@ nhs.net

Received 13 April 2023 Accepted 5 June 2023

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employer(s)) 2023. Re-use

permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published

by BMJ.

**To cite:** HodgettsTJ,

Naumann DN, Bowley DM. *BMJ Mil Health* Epub ahead

of print: [*please include* Day Month Year]. doi:10.1136/ military-2023-002435

**ABSTRACT**

The first year of the war in Ukraine has presented critical lessons for the UK’s Defence Medical Services (DMS) regarding its preparedness to support the nation for warfighting at scale. There are tactical, clinical, and strategic challenges that must be addressed. The war has exposed the limita-

tions of international humanitarian law and the

laws of armed conflict in protecting forward field hospitals from deliberate targeting. The DMS may need to employ measures such as disguise, decep- tion, and dispersal to provide care in a contested environment. The historical trend of disinvest- ment in military medical capability between major conflicts, known as the "Walker Dip," represents a clinical risk that must be mitigated. Even if this is achieved, clinical outcomes during large-scale warf- ighting are likely to be worse that those the nation has come to expect during more low-intensity conflicts. Effective civilian-military collaboration will be paramount to manage casualties at scale. Both novel and reversionary modes of transporta- tion may be required, such as the mass movement of casualties by train. The need for a sufficient and capable medical workforce, amid global shortages and post-COVID burnout, calls for further invest- ment. The DMS requires innovation and adapt- ability to harness the ability to adopt external ideas, translate successful innovations and address complex challenges. By addressing tactical vulner- abilities, enhancing clinical preparedness, fostering civilian-military collaboration, and embracing inno- vation, the DMS will be better equipped to support the UK and allied armed forces in future warf- ighting at scale.

**INTRODUCTION**

Napoleon Bonaparte recognised that when commanders move field hospitals to the front line of troops, they declare an intent to take casualties and thus an intent to fight. In January 2022, the international community observed, largely in open source materials, field hospitals appearing along the northern, eastern and southeastern borders of Ukraine. There were blood drives of university students, Russian military medical exercises that used large anaesthetised animal models, and medical evacuation chains in place back to St Petersburg. These declarations of intent warned of impending war.[1](#bookmark1) In summer 2022, Olena Chernenko, founder and CEO of the Ukrainian Medical Alliance stated that although ‘war’ had been everywhere in media and public communication, Ukraine’shospitals were unprepared for the invasion on a systemic level[.2](#bookmark2)

Would the UK’s Defence Medical Services (DMS) and National Health Service have been ready for an equivalent response to support the nation? In July 2022, the Royal United Services Institute Journal published an article entitled, *“You are the weakest link: the limits of UK Defence Medical Capability”.*[3](#bookmark3) This article articulates an ‘uncomfortable truth’: the war in Ukraine has highlighted the military medical capability gaps for warfighting that have accrued during the 30-year peace dividend following the Cold War. It concluded that recapitalising the DMS was essential if Op MOBILISE[4](#bookmark4) (the mission to ‘deter Russian aggression’ and ‘prevent war’) was to be realised. Now is the time to address the defi- ciencies in collective medical capability, taking the lessons from the war in Ukraine, which have been shared directly with the alliance Surgeon General community. Others from the USA have summarised some of the lessons learnt from the first year of war in Ukraine[.5](#bookmark5) The current article discusses the most important tactical, clinical and strategic lessons that apply to the UK’s DMS according to its Surgeon General, and some of the mitigations to the iden- tified medical challenges. Learning and adapting to these lessons through refinement in concepts and doctrine will ensure preparedness for future warf- ighting at scale.

**TACTICAL**

**Abuses of international humanitarian law and the laws of armed conflict**

It had previously been assumed that a principle (the Geneva Conventions), and an emblem (the Red Cross) would provide ‘protection’ in state- on-state conflict within forward field hospitals. However, Russian actions have shown this not to be the case. Long before the invasion of Ukraine, in 2016 Amnesty International reported that Russian and Syrian government forces were deliberately and systematically targeting hospitals and other medical facilities to pave the way for ground forces to advance on northern Aleppo.[6](#bookmark6) In that protracted conflict, health workers were forced underground or into unmarked buildings of opportunity to deliver care to wounded patients.[7](#bookmark7) Equally in Ukraine, it is now clear the international consensus is inadequate protection against a belligerent party who does not respect either the laws of armed conflict or humanitarian principles. In January 2023, Ambas- sador Neil Bush, the Head of the UK’s Delegation to the Organization for Security and Co-operation in Europe highlighted mounting evidence of war crimes committed by Russian forces in Ukraine while areas were under their control[.8](#bookmark8) In addition,

[BMJ](http://jramc.bmj.com) HodgettsTJ, *et al*. *BMJ Mil Health* 2023;**0**:1–4. doi:10.1136/military-2023-002435 1

BMJ Mil Health: first published as 10.1136/military-2023-002435 [o 3 Ju 3. d o h tp / il yhe th bmj com/![](/media/202412//1733471268.9805093.png)l![](/media/202412//1733471268.9901829.png)2fr![](/media/202412//1733471268.9988773.png)![](/media/202412//1733471269.0071294.png)![](/media/202412//1733471269.0178742.png)![](/media/202412//1733471269.026628.png)![](/media/202412//1733471269.0353618.png)n![](/media/202412//1733471269.0440547.png)oad![](/media/202412//1733471269.053879.png)![](/media/202412//1733471269.0625637.png)](http://militaryhealth.bmj.com/) on September 14, 2023 by guest Protected by copyright

**Analysis**

ongoing strikes on Ukraine’s cities, civilians and critical infra- structure is creating an enduring humanitarian impact on the Ukrainian population. Within weeks of the start of the invasion, multiple healthcare treatment facilities had been targeted by the regime, often with devastating consequences[.9](#bookmark9) In such circum- stances the DMS may need to make better use of disguise, decep- tion and dispersal, such as the use of underground car parks and basement contingency hospital wards to provide care to patients. Enhanced air defence protection for medical treatment facilities such as those at a military headquarters may be required[.10](#bookmark10)

**Protected ground Medical Evacuation**

Protected ground Medical Evacuation allows combat casualties to reach timely surgery (including ‘damage control surgery’) that can preserve life and maintain future function. This was one of the earliest priority-asks of Ukraine and has been met with wide international assistance. Furthermore, there has been a re-evaluation of reversionary methods of moving mass casu- alties over large distances while offering meaningful treatment. These have included hospital trains. With a degree of irony, it is acknowledged that the hospital train was a method first used after the battle of Balaklava in Crimea in 1854, and later refined to include a surgical capability as a Russian innovation during their war with Japan in 1904 by the surgeon Vera Gedroits.[11](#bookmark11) Up to 60% of Ukrainian military casualties have been moved east to west by train. As well as the parallel effort to explore how surgical teams can be mounted on an aircraft, it is necessary to also re-explore how such a capability might be used on a train when moving casualties for hundreds of miles.

**Transnational casualty movement**

The war in Ukraine has highlighted the need to address the requirement for transnational casualty regulation across and between continents. To manage *civilian* casualty distribution across Europe from Ukraine, the EU’s Emergency Response Coordination Centre has been used, supported by military STRATEVAC air assets, particularly from Germany and Norway. To manage *military* casualty redistribution, the new Multina- tional Military Coordination Centre in Koblenz has been used. Lessons from this experience are enhancing understanding for redistribution of the North Atlantic Treaty Organization (NATO) allied casualties in the event of the UK being involved in warfighting at scale.

**Medical supplies (project KOROVAI) and stockpiles**

Project KOROVAI is the initiative designed for the international community to come to Ukraine’s aid and to commit to gifting lethal and non-lethal aid. The project has subsequently been expanded to include coordination of medical materiel gifting. This aims to avoid key gaps in provision and avoid duplication of effort. In essence. it is the same function as a ‘wedding list’ and Korovai (коровай) is a symbolic bread baked for Ukrainian weddings, where it is cut and distributed to guests who offer gifts in exchange.

The COVID-19 pandemic demonstrated that ‘just in time’ logistics do not work, particularly when consumables (eg, personal protective equipment) are procured and supplied from a common source. If there is excessive demand by multiple nations on the supply chain, or if the supply chain is contested or disrupted by war, there is a risk of key shortages. In order to address this challenge, there are several key priorities; first to consider what critical equipment or consumables must be manu- factured from within the UK (‘sovereign capability’); second to

hold more stock and third, how to rotate this greater stock out and use it for healthcare provision, so it is not wasted.

**CLINICAL**

**Expectations for clinical outcomes when fighting at scale**

It is acknowledged there is an historical and cyclical disinvest- ment in military medical capability between major campaigns, known as the ‘Walker Dip’.[12](#bookmark12) Such a dip has been entered at the end of the contemporary Afghanistan campaign. It is not just a UK phenomenon, but has been mirrored across the NATO alliance. It explains why clinical outcomes improve through the course of a war, in part through restoration of capabilities and in part through innovation to match new signature injury or illness patterns. To offer reassurance, the current European war has been a catalyst for international military medical reinvestment: mitigating actions will drive medical capability collectively back up the curve.

Irrespectively, clinical outcomes will still be poorer during warfighting at scale than in low-intensity conflict. The crude outcomes of military casualties in Ukraine have been expressed as the ratio of Killed in Action to Wounded in Action, and these are less favourable than survival in the 21st century conflicts in Iraq and Afghanistan. Yet this is no surprise, given the volume of casualties, the contested evacuation and the propor- tion of wounding from heavy weaponry. It is a reminder for commanders, politicians and the public—including the families of Service personnel—to understand and accept that outcomes may be poorer in future conflicts of this kind. History confirms that more risk is accepted in wars of national survival than wars of choice. But today, the unattainable public expectation may be the sustainment of exquisite care previously afforded by the DMS for individual casualties in low-intensity conflict.

**Antimicrobial resistance**

Before the invasion, drug-resistant organisms were prevalent in Ukrainian hospitals. In a study of >9000 surgical patients, rates of surgical site infection were high (21%) with methicillin resistance reported in 35.7% of *Staphylococcus aureus* isolates.[13](#bookmark13) With antibiotics previously available over the counter, in August 2022 the Ukrainian Ministry of Health implemented a new process where all patients are required to obtain a prescription from a doctor before buying antibiotics. However, a combina- tion of a sustained influx of patients with complex wounds, delays to treatment, long turnaround time of laboratory tests and transport of patients over large geographical distances has created a ‘perfect storm’ for a major problem with antimicrobial resistance in Ukraine.[14](#bookmark14) The DMS will need to prepare for, and mitigate this risk if undertaking operations in similar scenarios.

**Chemical, Biological, Radiological & Nuclear (CBRN) considerations**

The Russian government supported Syria with military aid and direct military involvement since the beginning of the Syrian conflict in 2011. There have been multiple allegations of the use of chemical weapons in Syria (eg, the Khan Shay Sarin gas attack on 4 April 2017 that allegedly killed 90 civilians; and a chlorine gas attack on Douma on 7 April 2018, which allegedly killed between 40 and 50 people). The spectre of nuclear weapons has also been overtly threatened by Russia. In September 2022, Vladimir Putin stated: “*If the territorial integrity of our country is threatened, we will without doubt use all available means to protect Russia and our people. This is not a bluff ”*.[15](#bookmark15) NATO is committed to developing and maintaining necessary Chemical,

2 HodgettsTJ, *et al*. *BMJ Mil Health* 2023;**0**:1–4. doi:10.1136/military-2023-002435

BMJ Mil Health: first published as 10.1136/military-2023-002435 [o 3 Ju 3. d o h tp / il yhe th bmj com/![](/media/202412//1733471269.10345.png)l![](/media/202412//1733471269.113606.png)2fr![](/media/202412//1733471269.12231.png)![](/media/202412//1733471269.1309803.png)![](/media/202412//1733471269.1406765.png)![](/media/202412//1733471269.1502812.png)![](/media/202412//1733471269.158423.png)n![](/media/202412//1733471269.1697502.png)oad![](/media/202412//1733471269.1778257.png)![](/media/202412//1733471269.1874661.png)](http://militaryhealth.bmj.com/) on September 14, 2023 by guest Protected by copyright

**Analysis**

Biological, Radiological and Nuclear (CBRN) defence capa- bilities including intelligence, personnel, equipment, policies, plans, exercises and training. These are effectively integrated into NATO’s deterrence and defence posture; and there is a committment that societies will have the necessary resilience against CBRN threats. Additionally, there are trusted medical countermeasures, diagnostics and treatments, and NATO has re-energisedits policy on CBRN, signed off at the last Heads of State summit in Madrid[.16](#bookmark16)

**STRATEGIC**

**Civilian-military collaboration**

Collaboration between civilian and military organisations will be central to success in the management of casualties at scale. In peace, when the DMS is involved in expeditionary deploy- ments, these can rely on a high-income country’s Role 2 and Role 3 facilities for emergency care. In war, this may be more complex when the host nation’s civilian population has parallel increased demands on emergency ‘war surgery’ care. For stra- tegic evacuation, civilian air, rail and ferry assets will provide the necessary capacity. On arrival in the home nation, injured Service personnel would likely overwhelm any dedicated mili- tary hospital capacity and would need to be treated in civilian hospitals. This is absolute for those nations, including the UK, who no longer have independent military hospitals. Civil- military collaboration is understandably therefore at the heart of the new NATO Medical Support Capstone Concept, approved in 2022 by NATO’s Military Committee. In the 21st century, UK combat casualties have almost exclusively been received at the Role 4 hospital in Birmingham (currently the Queen Eliza- beth Hospital). With a higher number of casualties than recent conflicts, there may need to be many more receiving hospitals within the UK, requiring a level of civilian-military collaboration far beyond what has been required in the more recent conflicts.

**Medical workforce capability**

One of the greatest risks for warfare at scale is a sufficient and sufficiently capable work force, which is well understood through internal review.[17](#bookmark17) The fragility is compounded by external factors beyond control, including the global shortage of healthcare workers, an NHS under extreme pressure and post-COVID-19 burnout.[18](#bookmark18) The mitigation may be to re-invest in some areas where posts have been civilianised, de-enriched or deleted, particularly where this impacts on support to deploy- ability in the firm base. There is also the requirement to ensure ‘the offer’ to serve is at least as attractive as the NHS, when barriers to exit are extremely low.

**Innovating in crisis**

To innovate in crisis, it is necessary to harness the ability to be good ‘innovation adopters’ . This is the ability to take an external idea and rapidly bring it in to one’s own organisation. The conditions required to be a good ADOPTER are Agility, Deci- siveness, being Outcome-focused, politically aware, Tolerant of risk, Empowered and Rewarded.[19](#bookmark19) ‘Innovation translation’ is where innovation is spread to a different part of an organisation, to another organisation or internationally to an ally. An example of this might be the UK expertise in building military rehabil- itation capacity in Ukraine. However, it is not always straight- forward to effect change, especially if complex. For innovations to be successful, transformational leadership is required in the receiving organisations as well as responsive networks to effect and distribute change. This would also require innovations to be

relevant and adapted to the specific needs so that innovations are accepted, with life-enhancing impacts for patients. The DMS may wish to consider the eight-step model of complex change described by John Kotter when planning for large-scale change[.20](#bookmark20)

**CONCLUSION**

Vladimir Putin has consistently stated that: ‘*Russians and Ukrai- nians are one people—a single whole*’ and descendants of an ‘*Ancient Rus*’.[21](#bookmark21) This denial of Ukrainian statehood led to the illegal annexation of Crimea and the subsequent illegal and unprovoked invasion of Ukraine. The devastating impact of modern munitions on a civilian population and national critical infrastructure has revealed the true implications of ‘fighting at scale’ . There are tactical, clinical and strategic lessons to learn for the UK’s DMS. The challenge of retrieval of casualties from the point of wounding and their treatment in facilities that are no longer protected while within range of drone munitions and missiles is the catalyst to review and revise modern combat medical support. The Korovai principle of gifting what can be afforded to Ukrainian peers must be matched by the effort to ensure the DMS medical capabilities are ready to step up to provide the effective support to the UK and allied Armed Forces.

**Twitter** DN Naumann [@davidnnaumann](https://twitter.com/davidnnaumann) **Collaborators** N/A.

**Contributors** TJH designed and wrote the first version of the manuscript. DNN and DMB provided revisions and critical appraisal. All authors agreed on the final version. **Funding** The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

**Competing interests** None declared.

**Patient consent for publication** Not applicable. **Ethics approval** Not applicable.

**Provenance and peer review** Not commissioned; externally peer reviewed.

**Open access** This is an open access article distributed in accordance with the

Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which

permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited,appropriate credit is given, any changes made indicated, and the use is non-commercial. See: <http://creativecommons.org/licenses/by-nc/4.0/>.

**ORCID iD**

DN Naumann <http://orcid.org/0000-0003-2243-2325>

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HodgettsTJ, *et al*. *BMJ Mil Health* 2023;**0**:1–4. doi:10.1136/military-2023-002435 3

BMJ Mil Health: first published as 10.1136/military-2023-002435 [o 3 Ju 3. d o h tp / il yhe th bmj com/![](/media/202412//1733471269.2295377.png)l![](/media/202412//1733471269.2394345.png)2fr![](/media/202412//1733471269.249168.png)![](/media/202412//1733471269.2588992.png)![](/media/202412//1733471269.2683985.png)![](/media/202412//1733471269.2772005.png)![](/media/202412//1733471269.285074.png)n![](/media/202412//1733471269.2970648.png)oad![](/media/202412//1733471269.304879.png)![](/media/202412//1733471269.3156462.png)](http://militaryhealth.bmj.com/) on September 14, 2023 by guest Protected by copyright

**Analysis**

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4 HodgettsTJ, *et al*. *BMJ Mil Health* 2023;**0**:1–4. doi:10.1136/military-2023-002435