What Ukraine’s bloody battlefield is teaching medics

AMERICAN AND British intelligence agencies watched as Russia massed its 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.

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 front lines 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’t be 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.

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 may be 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 illustrates how 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 logs how 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.