One domain in which all militaries require constant developments and improvements is the medical field. The intense fighting in Ukraine shows the violent form that modern warfare can take; and while the Israelis’ campaigns in Gaza and Lebanon are asymmetric, to say the least, they are a stark reminder of the chaos, confusion, and intensity of urban combat. The two most transformative factors in today’s operational environment regarding casualty care are the looming spectre of war between modernised state armies (as opposed to the many “small wars” since the Cold War’s conclusion) which include vastly greater numbers and concentrations of men and materiel on the battlefield, and the subsequent challenges to casualty evacuation (CASEVAC) presented by this new reality.
“Small” wars have been assigned various names by scholars, strategists, and policy wonks over the years – “low intensity conflicts,” “operations other than war,” and so on. Whatever the best term may be, today’s wars in Ukraine, the Levant, Iran, or a few years ago in the Caucasus do not meet that definition. These are intense, combined arms fights characterised by massive exchanges of ordnance, high numbers of uniformed personnel as well as high numbers of casualties, and severe destruction and collateral damage.
Additionally, with the exception of the campaigns in Gaza and in Lebanon, in which Israel is fighting against non-state armies (which regardless, have been heavily funded, resourced, and trained by state actors), these are state-on-state wars, with all of the infrastructure and organisational capacity that comes with it. These fights are far more destructive and produce far greater numbers of casualties in far shorter timespans than anything that most European states have seen since the Second World War.
Days, Not Minutes
This fundamentally different operational environment has essentially negated the major planning factor that became so well-established during the Global War on Terror and other small wars of the past thirty years: the “Golden Hour” – a rule of thumb which dictated that, if a casualty was evacuated to higher levels of care within 60 minutes, his chances of survival drastically increased.
In the operating environment of say, Iraq, Afghanistan, or Mali, this was eminently feasible – neither Iraqi insurgents, the Taliban, nor West African militias possessed the assets to deny airspace – Western militaries themselves controlled the skies. Today’s wars do not work that way – air defense systems are ubiquitous, and the air dominance that the West has enjoyed is something, at the very least, not to take for granted. Even ground evacuation is far more dangerous, given the saturation of the skies with unmanned systems.
While the time factor of the Golden Hour remains as a medical consideration, the modern battlefield demands that soldiers be able to conduct prolonged casualty care (PCC) – in some cases, up to 72 hours. Doing this is a question of both of training and of equipment, since neither the training that line medics and soldiers undergo nor the equipment on hand is necessarily fit for purpose.
Every Little Helps
There have already been developments in the field of PCC. Blood, for instance, is crucial for keeping casualties alive. Blood-warming systems, whole blood collection sets (for drawing blood from a healthy soldier to save a potentially dying one), and packaging to enable the aerial delivery of blood products are all pieces of the equation for getting blood to a soldier who may be bleeding out and keeping him alive those extra few hours.
In care beyond blood, the Canadian company Thornhill Medical offers innovations such as a portable life support system called the MOVES SLC (Monitoring, Oxygen, Ventilator, Suction) and a portable, compact anesthesia vaporiser called the MADM (Mobile Anesthesia Delivery Module). Both systems are compact, relatively lightweight, and energy-efficient. These are the sorts of tools that will enable well-trained soldiers, whether designated medics or not, to keep themselves and their teammates alive long enough to be evacuated to higher levels of care.
This is a field that intrinsically has overlap with the broader medical field, since there will always be a demand for traumatic injury care. More particularly, there are important overlaps with the more niche medical requirements of extreme cold weather environments, or even space.
Get to the UAS!
The denial of movement presents a different challenge. Ukraine’s forces have already begun to employ unmanned ground vehicles (UGVs) and UAS for casualty evacuation, as well as for logistical resupply. NATO troops have begun experimenting and training with these types of systems, such as the FlyingBasket, a relatively large drone that can carry up to 100kg, and the Flowcopter FC-100, which can carry up to 650kg.
Here as well, there is tremendous potential for overlap with other sectors, such as logistics and delivery companies. A drone that drops off packages of blood or that delivers your latest Amazon order is still a drone carrying a thing from Point A to Point B.
While these unmanned systems are part of the solution, they are not its totality – PCC will remain the “main thing” for keeping wounded troopers alive. Often, it is the presence of a medic or even just a buddy that keeps a casualty responsive and ticking. Evacuating casualties via UAS opens up a whole new demand for training and for learning what works and what doesn’t.
More Innovation, More Lessons
In the early days of air CASEVAC and MEDEVAC during the Vietnam War, many helicopter crews witnessed casualties go from being stable and speaking on the ground to dying of shock once hauled onto helicopter skids. Quick shifts in body positioning would destabilise their cardiovascular systems and cause rapid blood loss and systemic collapse – not to mention the compounding effects of shock – first, from the wound itself, and then from riding through the air on skids.
While some of the lessons learned endure, such as more aggressive mechanical tourniquet application prior to evacuation, there is more work to be done. Armies need everything from realistic training aids to medical simulations, and there is no shortage of opportunities to develop new systems or to improve the legacy tools currently in use.
Let’s Bring Them Home
In closing, higher numbers of casualties are a brutal reality of the modern battlefield. With few exceptions, European states have not fought this kind of war since the Second World War. Ukraine’s methods – from using unmanned systems to directing ambulatory casualties to walk themselves to the rear – may not be ones that European countries are ready to adopt yet.
Ukraine is in an existential struggle, and its memory, certainly of World War II, is of the desperation and savagery of the Eastern Front. Most of Europe tends to be more casualty-averse. While this sentiment comes from a noble source, the reality of what we are seeing today should first remind us that there will be blood, and second, light a fire under us to develop every tool, technique, and practice that we can to mitigate the human damage and bring as many people as possible home alive.
CPT Francis Ambrogio is an armour officer in the U.S. Army, stationed in Bavaria. He is a graduate of the U.S. Military Academy at West Point and has served in a variety of armoured and light/mountain formations in the U.S., Asia, and Europe.
The views and opinions presented here are those of the authors and do not necessarily represent the views of the U.S. Army, the U.S. Department of Defense, or the U.S. government.
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