乌克兰血腥的战场教给医护人员的是什么

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乌克兰的血腥

战场是教医务人员

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**西方军队还没有处理过这个问题**

**自20世纪50年代以来的大规模伤亡人数**

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图片：泰勒 ·希克斯/纽约时报/Redux/Eyevine

2023年8月4日

美国和英国的情报机构监视了俄罗斯

在2022年的前几周，他们在与乌克兰的边境集结了军队。

他们知道弗拉基米尔 ·普京已经计划了一次入侵——他们确实知道了 偷了他的计划。但普京会继续接受它吗？一个指示器

卫生局局长蒂姆 ·霍奇茨少将说 英国军队，野战医院正在搬到

俄罗斯与乌克兰的边界。

这说明问题，但不是不话。俄罗斯已经部署了医院 过去的练习。更令人担忧的是持续的血液驱动

在全国的大学生中。红细胞只能维持6个红细胞

如果不冷冻，则为数周；捐赠者只能每三个月流血一次。甚至 更麻烦的是野战医院内部发生的事情。

俄罗斯的外科医生正在进行大型麻醉手术 动物“医疗指标和警告是战争的预测，”

霍吉特将军总结道。这是乌克兰对未来的一个重要教训 冲突

发生在乌克兰发生的战争是自1945年以来欧洲规模最大的一次战争。俄罗斯和 乌克兰的战斗规模和强度与西方军队一样

自朝鲜战争以来就没有遇到过。军事伤亡人数相差甚远 最近美国和欧洲的运动。美国输掉了

2001年至2019年期间，在阿富汗和伊拉克有7000名士兵。乌克兰 据泄露的数据，一年内损失了两倍多

美国的文件，俄罗斯要多出六到七倍。经验 将永远改变军事医学。

在阿富汗和伊拉克，美国的军队及其盟友取得了惊人的成就

在战时医疗保健方面取得的进展。因为大多数的死亡都发生在那里 在士兵们到达医院之前，通过撤离取得了很多好处

受伤的直升机部队在“黄金 ”内治疗他们 在这个时期，生存的几率要高得多。士兵 谁曾经会死的。

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受伤与死亡的比例约为3或4比1

越南的医疗保健水平较差，其价格飙升至高达10比1 图表在乌克兰，这个数字已经回落到越南的水平

熟悉这些机密数据的人说。不超过2%的美国人

士兵们在2001年后的战争中丧生或受伤；类似的

乌克兰的这个数字估计为510%。2022年的一项研究 皇家联合服务研究所，一个智库，建议，40%的

受伤的乌克兰人员正在遭受永久性的伤害。

这些数字在某种程度上反映了医疗保健的局限性 双方俄罗斯军队把步兵当作一次性的。受伤的

士兵们已经带着严重的弹片被送回了前线

伤口和心脏问题。塔尼莎 ·法扎尔是美国国立大学的学生

明尼苏达州是一名战争中的医疗保健专家，她说她的下巴下垂了 当她看到一段俄罗斯军官使用过时橡胶的视频时

止血带这是美国在阿富汗使用的那种方法 21世纪初。

就乌克兰而言，它正在从苏联过渡

风格护理。在2017年之前，它没有专业的战斗医疗人员干部， 该国武装部队的一名教官玛丽亚 ·纳扎洛娃说。凭借

2022年，它训练了650人，这是一个典型的海洋 百万人的军队。培训中心，缺少教员和

设施，现在每月准备的人数不到300人

在战场上，他们每个人都只接受了这四周的指导。

目前的反攻，正在迫使乌克兰军队

在无人机和大炮袭击的牙齿中穿过雷区，是

这加剧了医疗保健的负担。“我还没见过这样的峰值 自去年6月以来，止血带的需求

沃罗比奥夫是基辅的一名律师，他是六个不同的机构的志愿者 旅他补充说，胸封条和超声波设备也是如此

需要

结构性问题加剧了短缺问题。的供应

对前线部队的军事装备仍然是低效的和临时性的， 沃罗比奥夫先生说。高级医生把时间花在了填纸上 要求不稳定到达且数量小的表格。

前线单位和将军之间经常出现紧张关系

工作人员的中央医疗司令部，它认为其工作正在运作 而不是支持医院，而不是支持一线护理。它不提供

重要的设备，如便携式超声波或骨内访问设备， 当静脉找不到时，需要液体

纳扎罗娃女士说，这是震惊士兵的常见问题。超过90% 她的医疗用品是由志愿者购买的

说

这种官僚主义的内斗也有更严重的后果。

美国军队在21世纪初意识到要运送受伤的士兵 用“全 ”血，而不是血浆等成分，可以节省

生命去年夏天，乌克兰卫生部将这种做法合法化。这个 医疗指挥，在一阵官僚主义中，然后介入禁止它。但是 许多具有“现代思维 ”的乌克兰旅在继续这样做

无论如何，纳扎洛娃女士说，使用与当地血液的个人接触 捐赠中心。其结果是整个的护理水平不均衡

陆海空三军

西方军队将在一场大的战争中享有许多优势，包括

更熟练的人员和更好的设备。但是美国人和 欧洲军医承认大冲突将会

这对几十年来的医疗保健造成了巨大的冲击 针对缺乏大炮的对手发起的反叛乱行动，

导弹和无人机。

乘坐直升机，这对运送伤员至关重要。刚才

在2001年至2009年期间，有70架美国飞机被大火击落

阿富汗和伊拉克。俄罗斯在17个月内损失了90人。这个

认识到下一场战争可能会在空中发生非常不同

这个优势已经改变了美国和北约内部的许多范式 阿拉巴马大学的教授约翰 ·霍尔科姆说

他领导了美国陆军的外科研究所。会有

医院外的“长期现场护理 ”。“临床结果将是 可怜的，”霍吉特将军警告说。

受伤的模式也会有所不同。大约79%的美国伤亡人数是在 2001年9月11日袭击后的战争来自于

简易爆炸装置。超过70%的乌克兰人伤亡

根据最近的一篇论文，是来自火炮和火箭弹击 发表在《美国外科医生学会杂志》上。这些

往往会同时影响到更多的士兵，造成“ 多重性创伤 ”

-损伤身体的多个部位和器官。

大规模治疗此类伤害将对欧洲军队征税。考虑血液。 这是联盟的一种“ 战略商品 ”

伦敦国王学院的军事医疗后勤专家。一支军队

不能提供它的医疗保健系统有可能“系统性崩溃 ”

士气 ”，他警告说。Ti博士给出了爱沙尼亚的例子：它的主要原因

和平时期的血液储备可能在一天的战争中就会耗尽 北约对使用率的标准假设)。

然而，储存血液并不像储存弹药。它的保质期很新鲜

是数周（冷冻时为几个月） ，而不是数年。从冷冻中解冻 需要时间。此外，英国的献血水平也经常下降

霍奇茨将军指出，这是一个低于一周的外汇储备。战争是 帮助解决北约以前很棘手的法律问题

血液制品和药物的互操作性。英国现在正在投资 生产自己的冻干等离子体，以前一直依赖于

法国和德国稀缺的生产可能会被淹没 战时。

另一个问题是如何转移数万名受伤的士兵。

7月11日，北约领导人批准了北约的首次全面行动

自冷战以来的国防计划。其中包括群众群众的具体计划 横跨欧洲的伤亡人员运输，包括如何分配伤亡人员

这是一个多年来一直被忽视的问题。北约医疗

局长们，有时也有乌克兰卫生局局长加入 定期开会，测试这些程序在战时的表现。

多达60%的乌克兰军事伤亡人员都是通过铁路转移的。

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医护人员曾经希望医院能在战区脱颖而出。教训

俄罗斯来自乌克兰，俄罗斯在那里袭击了带有大型红十字会的设施 在屋顶上，也就是说，融入其中可能会更好。世界卫生组织

该组织估计，已经发生了近900起袭击事件

战争中的卫生设施（见地图） 。医生正在考虑 如何硬化、伪装或分散他们的设施。但是光和

敏捷的野战医院将不可避免地提供更多有限的护理。另一个

日益增长的挑战是如何确保电子产品的排放 医疗设备不能作为敌人炸弹的灯塔。

**准备行动**

这场战争也将核武器重新提入了议程。在

今年秋天，西方领导人越来越担心俄罗斯正准备这样做 使用战术核武器。美国、英国和法国都警告说

克里姆林宫表示，如果它能这样做，它将面临严重的军事后果

步骤；危险消退了。在冷战期间，北约计划进行作战 通过核战场。这些计划在上世纪90年代逐渐消失。

许多官员现在担心，美国及其盟友在医疗上存在问题

对核冲突毫无准备。大量的燃烧工具包将会是 例如，需要。

最后，乌克兰说明了技术正在如何改变军事力量

医学美国中校于2021年2月发表的一项研究报告称 约瑟夫 ·马德里和他的美国陆军外科研究所的同事 研究检查了1267名患者的记录

外伤其中一半的人没有接受任何挽救生命的干预 路线可能被无人机安全移动。

乌克兰正在检验这一理论。它已经使用了大型货运无人机， 可携带180公斤货物达70公里，疏散伤员

成为第一个使用这种机器人的国家

救伤直升机“ 随着技术的进步，”马德里中校写道

和他的合著者，“无人机上的机器人可能会带来痛苦 药物，血液制品，氧气，气道管理，甚至

尽管无人机也面临着同样的风险 法扎尔博士指出。

挑战是如何从这类实验和乌克兰更广泛的实验中学习 经验这就需要把轶事变成硬数据。美洲

已经提出帮助乌克兰建立一个类似的“创伤登记处 ”吗 在阿富汗和伊拉克使用，一个记录病人状况的数据库

受伤，他们如何得到治疗，他们的表现如何。分析将

不仅有利于盟军军队，也有利于更广泛的公众。霍尔科姆博士 说他能够减少创伤死亡的人数

阿拉巴马大学伯明翰分校，申请30%

在军队中获得的技能。乌克兰的痛苦将带来医疗收益。■

*更正（2023年8月7日）：本文的早期版本拼错了* *约翰霍尔科姆的名字。对不起。*

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What Ukraine’s bloody

battlefield is teaching medics

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**Western armies have not dealt with mass casualties since the 1950s**

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image: Tyler Hicks/The New York Times/Redux/Eyevine Aug 4th 2023

AMERICAN AND British intelligence agencies watched as Russia

massedits troops on the border with Ukraine in the early weeks of 2022. They knew that Vladimir Putin had planned an invasion—they had

stolen his plans. But would Mr Putin go through with it? One indicator that he would, says Major-General Tim Hodgetts, the surgeon-general of Britain’s armed forces, was that field hospitals were moving to

Russia’s border with Ukraine.

That was telling, but not damning. Russia had deployed hospitals for exercises in the past. More worrying were the ongoing blood drives

among the country’s university students. Red blood cells last only six weeks if not frozen; donors can be bled only every three months. Even more troubling was what was happening inside the field hospitals.

Russian surgeons were practising operations on large, anaesthetised animals. “Medical indicators and warnings are predictive of war,”

concludes General Hodgetts. It is a vital lesson from Ukraine for future conflicts.

The war in Ukraine is the largest in Europe since 1945.Russia and

Ukraine have fought at a scale and intensity that Western armies have not encountered since the Korean war. Military casualties have dwarfed those of recent American and European campaigns. America lost over 7,000 troops in Afghanistan and Iraq between 2001 and 2019. Ukraine has lost more than twice as many in a year, according to leaked

American documents, Russia six to seven times more. The experience will change military medicine for good.

In Afghanistan and Iraq, America’s army and its allies made astonishing progress in wartime medical care. Since the majority of deaths occur

before soldiers arrive at a hospital, much was gained by evacuating wounded troops by helicopter and treating them within the “golden hour”, a period in which the chance of survival is far higher. Soldiers who once would have died pulled through.

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The ratio of those wounded to killed, around three- or four-to-one in

Vietnam, where care was poorer, shot up to as high as ten-to-one (see chart). In Ukraine the figure has plummeted back to Vietnam levels, say people familiar with the classified data. No more than 2% of American soldiers were killed or wounded in the post-2001 wars; the comparable figure is estimated at 5-10% for Ukraine. A study from 2022 by the

Royal United Services Institute, a think-tank, suggested that 40% of wounded Ukrainian personnel were suffering permanent injuries.

To a certain extent these figures reflect the limitations of medical care on both sides. Russia’s army treats infantry as disposable. Wounded

soldiers have been sent back to the frontlines with serious shrapnel wounds and cardiac problems. Tanisha Fazal of the University of

Minnesota, an expert on medical care in war, says her jaw dropped

when she saw a video of a Russian officer using an obsolete rubber

tourniquet. It was of the sort that America used in Afghanistan in the early 2000s.

For its part, Ukraine is in the midst of a transition away from Soviet- style care. Before 2017 it had no professional cadre of combat medics, says Maria Nazarova, an instructor in the country’s armed forces. By 2022 it had trained 650 of them, a drop in the ocean for a notional

million-man army. The training centre, short of instructors and

facilities, now prepares fewer than 300 people per month for the

battlefield,each of whom has had just those four weeks of instruction.

The current counter-offensive, which is forcing Ukrainian troops to cross minefields in the teeth of drone and artillery attacks, is

intensifying the burden on medical care. “I have not seen such a spike in the demand for tourniquets since June last year,” says Evgen

Vorobiov, a lawyer in Kyiv who works as a volunteer with six different brigades. He adds that chest seals and ultrasound devices are also

needed.

The shortages are compounded by structural problems. The supply of military equipment to front-line units remains inefficient and ad hoc, says Mr Vorobiov. Senior medics spend their time filling out paper

forms to request supplies that arrive erratically and in small quantities. There is frequent tension between front-line units and the general

staff’s central medical command, which sees its job as running

hospitals rather than supporting front-line care. It does not provide

vital kit, such as portable ultrasound or intraosseous access devices,

which are needed to get fluids into patients when veins can’tbe found —a common problem for soldiers in shock, says Ms Nazarova. Over 90%

of medical supplies for combat medics are purchased by volunteers, she says.

This bureaucratic infighting has more serious consequences, too.

America’s army realised in the 2000s that transfusing wounded soldiers with “whole” blood, rather than components like plasma, was saving

lives. Last summer Ukraine’s health ministry legalised that practice. The medical command, in a fit of bureaucracy, then stepped in to ban it. But many “modern-thinking” Ukrainian brigades continue doing it

regardless,says Ms Nazarova, using personal contacts with local blood- donation centres. The result is uneven levels of care throughout the

armed forces.

Western armies would enjoy many advantages in a big war, including more skilled personnel and better equipment. But American and

European military doctors acknowledge that a large conflict would prove a huge shock to medical care honed over decades of

counterinsurgency campaigns against opponents lacking in artillery, missiles and drones.

Take helicopters, which are critical for transporting the wounded. Just

70 American ones were downed by fire between 2001 and 2009 in Afghanistan and Iraq. Russia has lost 90 in 17 months. “This

recognition that the next war will likely be very different in air

superiority has changed lots of paradigms within the US and NATO

militaries,” says John Holcomb, a professor at the University of Alabama who led the US Army’s Institute of Surgical Research. There will be

“prolonged field care” outside hospitals. “Clinical outcomes will be poor,” warns General Hodgetts.

Injury patterns will differ, too. Around 79% of America’s casualties in the wars after the attacks of September 11th, 2001 were from

improvised explosive devices. More than 70% of Ukrainian casualties are from artillery and rocket barrages, according to a recent paper

published in the Journal of the American College of Surgeons. These

tend to affect a larger number of soldiers at once, causing “polytrauma” —damage to multiple body parts and organs.

Treating such injuries at scale will tax European armies. Consider blood.

It is a “strategic commodity” for the alliance, writes Ronald Ti, a

military-medical logistician at King’s College London. A military

health-care system that cannot provide it risks “systemic collapse of morale”, he warns. Dr Ti gives the example of Estonia: its main

peacetime stock of blood could be exhausted in a single day of war (on NATO’s standard assumptions about rates of use).

Yet stockpiling blood is not like storing ammo. Its shelf life when fresh is weeks (and,when frozen, months), not years. Thawing it from frozen takes time. Moreover, blood-donation levels in Britain routinely drop

below a week’s worth of reserves, notes General Hodgetts. The war is

helping to resolve previously knotty legal issues in NATO around the

interoperability of blood products and drugs. Britain is now investing to produce its own freeze-dried plasma, having previously depended on

scarce French and German production that might be swamped in wartime.

Another problem is how to shift tens of thousands of wounded soldiers. On July 11th NATO leaders approved the alliance’s first comprehensive defence plans since the cold war. They included specific plans for mass- casualty transport across Europe, including how to distribute casualties among different allies, an issue neglected for years. NATO medical

chiefs, sometimes joined by Ukraine’s surgeon-general, have been

meeting regularly to test how those procedures would fare in wartime. Up to 60% of Ukraine’s military casualties have been moved by rail.

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Medics once wanted hospitals to stand out in a war zone. The lesson from Ukraine, where Russia has struck facilities with large red crosses on the roof, is that it maybe better to blend in. The World Health

Organisation estimates that there have been almost 900 attacks on

health facilities in the war (see map). Medical doctors are considering how to harden, camouflage or disperse their facilities. But light and

agile field hospitals will inevitably provide more limited care. Another growing challenge is how to ensure that the electronic emissions of medical equipment do not serve as a beacon to enemy bombs.

**Ready for action**

The war has also put nuclear weapons back on the agenda. In the

autumn Western leaders grew concerned that Russia was preparing to use tactical nuclear weapons. America, Britain and France warned the Kremlin that it would face serious military consequences if it took that step; the danger subsided. In the cold war NATO planned to fight

through a nuclear battlefield. Those plans faded away in the 1990s. Many officials now worry that America and its allies are medically unprepared for nuclear conflict. Vast numbers of burn kits would be needed, for example.

Finally, Ukraine illustrateshow technology is changing military

medicine. A study published in February 2021 by Lieutenant-Colonel

Joseph Maddry and his colleagues at the US Army’s Institute of Surgical Research examined the records of 1,267 patients transported with

traumatic injuries. Half did not receive any life-saving intervention en route and so might have been moved safely by drone.

Ukraine is testing that theory. It has already used large cargo drones, capable of carrying 180kg loads up to 70km,to evacuate wounded

personnel,becoming the first country to conduct this sort of robotic medevac. “As technology advances,” write Lieutenant-Colonel Maddry and his co-authors, “robotics aboard [drones] could provide pain

medications, blood products, oxygen, airway management, and even surgical procedures”—though the drones are subject to the same risks as helicopters, points out Dr Fazal.

The challenge is to learn from such experiments and Ukraine’s broader experience. That requires turning anecdotes into hard data. America

has offered to help Ukraine build a “trauma registry” of the sort that it used in Afghanistan and Iraq, a database which logshow patients are

injured, how they have been treated and how they fare. Analysis will

benefit not just allied armies, but also the wider public. Dr Holcomb has said that he was able to reduce the number of trauma deaths at his

hospital, the University of Alabama at Birmingham, by 30% by applying skills picked up in the army. Ukraine’s pain will lead to medical gains. .

*Correction (August 7th 2023): An earlier version of this article misspelt John Holcomb’s name. Sorry.*