Winston Churchill, when asked about the investment made in military medical research during WWII remarked, ‘to enhance the tomorrow of military medicine, we must look at the military medicine of the past’ (Chatfield-Ball et al 2015). Throughout history there has been a strong association with reviewing previous or current conflicts to influence the medical capability of tomorrow. With the recent conflicts in the modern era, it is prudent we learn not only from the lessons learned during recent wars, but specifically the ongoing war in Ukraine.
Throughout this conflict, militaries around the world have eagerly reviewed and analysed available medical data, and rapidly applying their findings to their own capabilities. The Australian Army in particular, is investing in surgical capabilities that offer the ability to move with the battlegroup and have hands on patients within the hour. This paper will explore what Ukraine has and will continue to teach us, that will inevitably shape the way the Australian Army operates their surgical capabilities in the future operating environment.
One of the biggest lessons learned or rather reinforced during this war is the emphasis on damage control surgery (DCS). DCS is by no means a fix, but it provides the opportunity for time to evacuate the patient in a stable condition and contributes to lower morbidity and mortality. More importantly, out of this conflict, DCS surgery allows for more casualties to reach the operating table, and thus for more casualties than before to reach the next step of the land-based trauma system and receive definitive surgical interventions and intensive care.
This has been shown to contribute not only to lowered mortality and morbidity of casualties who have had DCS when they reach definitive surgery (DS) but has also shown to have more patients reaching rehabilitation facilities further back in the trauma system, and even back to the battlefield, in a suitable condition and timeframe.
Investing in DCS has heightened some of the limitations that need to be rapidly addressed, this includes investing in more medical evacuation assistants to effectually monitor and care for these patients upon evacuation and free up the DCS capability (ACSb 2021). DCS automatically requires medical personal to continue the evacuation to the next level of care, and the solution raised by the Ukrainian Forces was up-skilling medics and utilising combat paramedics in this role. Another unique solution was using already established urban infrastructure and having mobile theatres and ICUs on the train network to move more casualties around the battlespace (ACSb 2021).
A vital lesson that has been raised during the conflict is to have low signature and highly mobile medical assets. Meeting this requirement often results in limitations of capability or number of casualties to be afforded surgical interventions. However, this was not the case during the Ukrainian conflict where the capability become mobile, yet still met the overall needs and number of casualties as its predecessors.
This was met by investing in a capability that molded into the modern surrounding infrastructure. This allowed for the concealed shelter required for an asset of this means, and meant that this asset could pull its resources into the medical equipment needed to perform DCS in the field.
To learn from what the Ukrainian forces are doing now, we need to adapt our equipment to be mobile, agile, and flexible to suit the operating environment (ACSa 2023). We also need to invest in multi-purpose equipment that allows us to effectively care for our patients without taking up unnecessary resources. Simply, our assets need to move towards a focus on moving the equipment, clinicians, and surgical items rather than the infrastructure of the DCS. We must have the adaptability to use the direct surgical equipment and augment into an urban or civilian setting in the battlespace.
Some of the advancements in medical research demonstrate that surgical interventions begin with point of injury (POI) care. What is meant by this is the ability to have DCS is only afforded by the sound, swift and effective clinical interventions undertaken in the POI setting. A surgeon cannot stop an arterial bleed if a tourniquet was not put on it first by a first responder. The Ukrainian forces have used the surgical team to highlight this importance in training of the front-line responders and soldiers.
This not only adds training value for these members but allows the surgical team to influence and be involved with the care at the POI (Stucky et al 2021). This has been shown to boost performance in POI skills and has seen casualties come through resus and into the operating theatre in a more stable clinical state as compared to the beginning of the conflict.
It also takes on an important notion which the Australian Army needs to reinforce, that surgical interventions are a vital asset in the land-based trauma system, but it is only one link in this chain. There needs to be an importance on strengthening every link in the chain, thus allowing for overall positive clinical outcomes for our casualties.
Every medical asset’s greatest challenge, is the need for rapid and urgent blood in trauma casualties that require DCS. This challenge will undoubtedly be an ongoing and difficult problem to solve. However, if we look to what is occurring in Ukraine, they have some interesting and perhaps possible interim solutions to this problem. They predominantly utilise a ‘walking blood bank’ method where blood is taken immediately from fit donors on the battlefield.
This allows for rapid and urgent blood to be given to the casualty. Blood in trauma dramatically improves critical interventions used by clinicians to treat battle casualties (US Army 2022). However, in the surgical environment, some of the Ukrainian trauma theatres are using ‘cell saver’, which is a vital piece of equipment that allows for the surgical teams to suction and salvage the casualty’s blood to then be filtered and transferred back into the patient.
This is a cost and resource effective solution that requires some ongoing training and equipment maintenance by the perioperative nurses to ensure that if there is no means to access blood, we can salvage the blood from the patient and give it back to them. There are preliminary studies regarding ‘cell saver’, and it is in the Australian Army’s best interest to eagerly review these findings. This is a simple yet extremely beneficial intervention, that replaces blood loss and minimises the common complications associated with blood such as collection, transport, maintenance, and cross match contamination issues (ACSa 2023).
The Ukrainian forces have also highlighted the need for every clinician to be trained in both clinical and military skills. If we translate this into our own capability, this means that every clinician must understand that they are first and foremost a military clinician. This means being able to step into any clinical situation within their scope and perform well in a multitude of areas and clinical specialties (Stucky et al 2020).
But as seen in Ukraine, this also means being versed in a military sense. Examples include some surgeons currently posted to the front line, also work in transport and maintenance of the health vehicles, as well as conducting surgeries and assisting other doctors within the military hospital. To decrease our signature on the ground and achieve objectives such as mobility and proximity, we must be realistic in the sense that to achieve this we need to be able to be self-sufficient in the field.
We can’t rely on other sustainable assets to maintain our capability; we must do that for ourselves. This means investing in clinicians to be well versed and exposed to cross training in many areas within a hospital environment, and versed in some military skills that were once deemed not needed for a clinician (Militaire Spectator 2023).
Finally, evidence coming out of Ukraine is supporting the new land-based trauma algorithm of reaching resus within 15 minutes, blood within 30 minutes and surgery within an hour. This means that our surgical capability needs to be flexible to work with and excel within the algorithm. This is a difficult algorithm to meet, but it is a standard being set and supported by the evidence in Ukraine.
This translates to having viable options and solutions for accessibility to blood on the battlespace, and to having a mobile yet impactful DCS capability (ACSa 2023). We need solutions that are light, maneuverable and offer a great variety of clinical needs. Currently, walking blood bank and cell saver are assisting in meeting this timeframe both in reuse and in theatre.
This is an exciting time for our current surgical capabilities to review, reflect and evolve into the capability needed to meet this algorithm and meet the changing warfare needs of our Defence Force (ACSb 2021).
To prepare and look toward the inevitable conflict of tomorrow, it is vital that we look at conflicts of past to learn, review, and ultimately implement into our practice. Military medicine is dynamic and requires the ability to look at the past and leverage this as we look toward the future with innovation, determination, and a desire for excellence.