What will medicine on the battlefield look like?

[Blackadder1916]

What will medicine on the battlefield look like?

A few weeks ago @Staff Weenie posted an off-hand question in the logistic vehicle modernization thread that caught my attention and started me thinking (a dangerous development). Thus it led to my opening question. But taking it one bite at a time, what should that ambulance look like?

Hmmm, I wonder if Roshel could produce an Ambulance variant for use from R2 to R3, possibly even from R1 to R2? Something that can hold up to four litter patients.

There were a couple of subsequent posts in response.

I suspect they could easily do it, but would need some confirmed orders. My guess looking at the vehicle is they could likley raise the roof by 6" to possibly a 1' without any major changes to the vehicle or body. There is likley a point where the higher armour structure starts requiring a major redesign and weight distribution, suspension changes. I suspect they likley have a good idea where that point is at.

I’m real torn on roles you mention. I see it as ‘a little bit pregnant’.

1) I don’t think it fits the bill for a CP - as in a heavy or medium unit that is a LAV or the MSV SMP for Bde. For a light unit, it’s too big and bulky, and the ideal of a light vehicle Box CP is counter to the general doctrine for light forces — at least at the unit level. Yeah I’m not a fan of Arty units doing it either for Bty or Reg’t CP’s for a bunch of reasons.

2) Same sort of thought goes to the Ambulance role. It should be a LAV for the LAV entities. For light units - you’re more looking at an evac vehicle so the MRZR or ISV are probably better in that way - as they have vastly better mobility.


Honestly if the CA properly equipped all of its units - the idea of something like this would be relegated to the trash or as an emergency interim option for national mobilization.

Valid contributions, but my initial thought (and I mean no disrespect to your experiences) was "typical uninformed operators who don't know how the medical system works once the casualty leaves their sight". But to be honest, there are probably some BGHs in the RCMS world who also don't know - there certainly were some back decades ago (up to 5 decades) when I worked in the back of 3/4 ton, 5/4 ton, M113, crash amb, road amb, MLVW (no duff in Rwanda) or commanded Unimog, LSVW and Mercedes bus ambulances.

I'll pause momentarily while someone calls me an out of date arsehole.

I perked up when @Staff Weenie raised the issue of R2 to R3 ground evac. In our battle group or brigade group focused army little attention has been paid to the echelons above what we've cobbled together and put into the field (an exception may have been 333 ATC in CFE over 30 years ago). In one of the few official documents I've been able to find online about Canadian operational HSS, Role 1 is the only priority specifically mentioned.

Health Services Modernization - Modern and Ready: A Vision for the CAF Health System - Canada.ca

Health Services Modernization - Modern and Ready: A Vision for the CAF Health System

www.canada.ca

MEDEVAC Modernization. CFHS is significantly under resourced in medevac capability for operations and training. Although some vehicle capability enhancements have been achieved through the support of the environments with the ACSV armoured ambulance project as an example, there remains a disconnect between doctrinal medevac requirements and current procurement allocations. CFHS modernization has an incentive to leverage future technological advances to confront this challenge which might include access to remotely piloted systems. Ground Role 1 evacuation vehicle modernization is an operational imperative for any HS NATO interoperability function or capability.

Online Canadian references are sparce. One other I did find (from the usual suspects, Homer Tien and Andy Beckett) is two years old, so while it does touch on the evolution in battlefield HSS that is being seen in the Russo-Ukrainian war, it may not be as up to date as other sources.

https://jmvfh.utpjournals.press/doi/10.3138/jmvfh-2022-0006

Medical support for future large-scale combat operations

Assumptions for how the Canadian Armed Forces cares for injured soldiers on the battlefield may no longer hold true. Previous treatments were designed for counterinsurgency operations where Allied forces dominated the air and land during operations. However, the recent fighting in Ukraine highlights the need to develop a doctrine for pre-hospital care on the battlefield for large-scale combat operations. . . .

Their monogram doesn't discuss vehicle evacuation but it does contain a common theme found in other discussions of how things are different - that Ukraine is not Afghanistan.

Transferable military medical lessons from the Russo-Ukraine war

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

militaryhealth.bmj.com

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 casualties 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 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.

Medic on the Battlefield

The experiences of the missions in Iraq and Afghanistan have transformed military medicine, and helped develop the skills of medical personnel. Now it is time for another lesson – the war in Ukraine has shown that rescuers must focus their particular...

www.polska-zbrojna.pl

Afghanistan is a closed chapter for the Polish army, but not far from our borders there is an ongoing armed conflict of an entirely different nature. The heavy fights in Ukraine show the difficulties their forces have with medical support for the fighting subdivisions. The Ukrainian armed forces lack well-trained medics, there are serious problems with evacuating the wounded from the battlefield. There is no possibility of using MEDEVAC helicopters, and due to artillery shelling, evacuation by land takes a long time.

Lessons Learned from the War in Ukraine for the Bundeswehr Medical Service

Lessons learned from the War in Ukraine
During a COMEDS (Committee of the Chiefs of Military Medical Services in NATO) plenary in 2023, the Ukrainian Surgeon General presented an initial evaluation of the current conflict in Ukraine from a medical service point of view. His presentation was the first available medical report from a war on the European soil since World War II and provided the ideal opportunity to review the assumptions and rationales used to date in the Bundeswehr medical support planning process. In this context, six lessons can be identified:

1. The necessary protection level of medical forces during operations. Like in Syria, Afghanistan and Iraq, the distinctive emblem is barely observed or completely ignored by the Russian Armed Forces in the Ukraine.

2. Comparative analysis of the casualty rates of the personnel involved and their injury categories. That tells us something about the quantity and the quality of the required medical resources.

3. Evaluation of medical evacuation (MEDEVAC) with regard to the transport assets employed and the number of patients to be moved.

4. High mobility and flexibility of the elements of the MEDEVAC chain with regard to the availability of forces, space and time.

5. Need for interministerial health care in the sense that health care is a whole-of-government responsibility.

6. Relevance of medical support for the morale and operational effectiveness of armed forces.

At present, for example, the patient evacuation organisation is led by the Ukrainian Ministry of Health. The following problem areas are more than clear: long MEDEVAC times; overload of the hospitals; exhaustion of evacuation capacities; and, lack of expertise.

According to the assessment of the World Health Organisation, this leads to a qualitative and quantitative overstretch of the Ukrainian Ministry of Health and generally results in an insufficient patient evacuation organisation. Against this background, and considering a national/collective defence scenario, it may be appropriate for the German Federal Ministry of Defence to relocate the patient evacuation organisation in Germany with its capabilities and skills available so far. In order to exploit the existing potential, it is also indispensable to further expand the areas of digitalisation and resources.

So, what should that ambulance (or whatever ground evacuation assets) look like? As capacity was a factor in Staff Weenie's original post and various increases or limitations in size were mentioned in the couple of responses, what does that vehicle need? Or, maybe the question should be "what should those ambulances look like?"

And while it can be demoralizing when one is told that "size matters", there is truth in that for ambulances as for other more social interactions. One size that matters is:



I've had a few experiences when the interior space was inadequate.

 

[Blackadder1916]

Ambulances . . .

In the Infantry vehicle thread one possibility mentioned is the JLTV. While there is no ambulance variant adopted, there was a prototype developed. I'll include it as an example of (IMHO) something that looks cool, but is impractical.

https://www.militarytrader.com/mv-101/l-atv-ambulance-premiered

My objection is the two hatches through which the patients are slid into the amb. While much is made of assisted loading mechanisms aiding the crew, it is not unusual for the need to have someone be alongside the patient either handling equipment (ambu, IVs etc) or monitoring the patient while loading. As I mentioned in previous post about inadequate dimensions, that was primarily when loading patients with traction splints or eternal fixation devices; they can extend past the length or width of the litter depending on the device.

 

[Blackadder1916]

A comprehensive set-up.

 

[Colin Parkinson]

My grandfather was stretcherbearer in WWI. They often used POWs to help carry wounded, as they had to go back anyways. I have seen and been backed by 1/4 ton ambulances, 3/4 and 5/4. The Jeep optimistically took four. With no ability to treat. The 3/4 allowed minimal treatment, the 5/4 you could actually do something. I saw the M113 ambulance version, but no experience with them.

Really the first stage is evacuating a wounded solider(s) that can't walk to where a vehicle can reach them.

At that stage you want something armoured and good cross country performance either a tracked APC or LAV based.

The option is to have the more expensive and most likley to be hit stay closer to the front. With possibly staging to a lightly armoured ambulance to complete the journey to advanced care.

 

[Colin Parkinson]

Also any data on how much the Russian respect the Red Cross and such marked vehicles and field hospitals?

 

[Blackadder1916]

Also any data on how much the Russian respect the Red Cross and such marked vehicles and field hospitals?

Russian targeting of known and marked medical vehicles, facilities and emergency responders, both military and civilian is widespread in Ukraine just as it was in Syria.

Attacking hospitals is part of Putin’s plan

Russia’s “total war” tactics are aimed at forcing local populations to press the government to capitulate, experts say.

www.politico.eu

. . . So far, Russia has damaged more than 1,600 medical centers and destroyed more than 200 hospitals in Ukraine, the Health Ministry of Ukraine reported in June. Russian forces also target ambulances and other medical evacuation vehicles in frontline regions.

Similar things happened in Syria, where Russia was accused of bombing multiple hospitals throughout its involvement in the military campaign. Physicians for Human Rights, an NGO that monitors attacks on health care infrastructure, found that Russian or Syrian forces were responsible for attacking 541 medical facilities over a 10-year period.

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)01922-6/fulltext

So-called double-tap missile attacks are increasingly being used in Ukraine, where war has already had a devastating impact on health care. Lily Hyde reports.

On Sept 1, in Kharkiv, eastern Ukraine, an ambulance team answered an emergency call from near a shopping centre, where a Russian missile strike had injured several people. According to Viktor Zabashka, who heads Kharkiv's emergency medical services, the team was monitoring the airspace and could see that a missile was in the air. As soon as it had flown over, they parked at the site. Then another rocket landed without warning. “No one knew it was in the air”, Zabashka told The Lancet. Both ambulance medics were wounded in the second strike. The paramedic Yevhen Yurko, who had just turned 21, later died in hospital.

Air strikes followed shortly by a second attack in the same place are known as double-tap strikes. They predominantly target first responders—medics and other emergency services—and Russia is increasingly using them in its full-scale war in Ukraine, which is already having a devastating impact on health care. “Double-tap strikes are a devastating and deliberate tactic of Russian forces. Such attacks are aimed at both patients and emergency workers, so that they are not able to provide the full necessary assistance to victims”, said Serhiy Dubrov, Ukraine's First Deputy Minister of Health. Since February, 2022, WHO has confirmed 1973 attacks on health-care facilities, health transport and supply, staff, and patients in Ukraine—the highest number the agency has ever recorded in any humanitarian emergency. Since December, 2023, attacks are occurring on a near-daily basis, and include more and more double-tap strikes.

 

[medicineman]

So I've used 1/4 ton Jeep and Iltis ambs, 1 ton, 5/4 ton gas and 5/4 ton diesel CUCV, LSVW, done mass cas rig up for MLVW, played with an M113, used Unimog 1500, and 2 variants of Bison, 1 of which I crew commanded on a regular basis. Problem with armoured ambulances is largely space, however their main job is to get away from the FEBA with some semblance of survivability. Jeep and Iltis ambulances were essentially meat wagons as well - quickly move someone back OR move stable'ish folks to R2, since it was nigh on impossible to look after folks properly. The CUCV was roomy, but the loading trays ere a bit tricky and finicky to use, they had a walk through box to cab, which was nice; however the 4x4 system was mentally challenged, in that you had to get out and lock the hubs up by hand on the front wheels, which if already buried in mud was difficult at best. 5/4 gas ones weren't too bad, just older than dirt's grandparents by the time I got to my Amb platoon, so were kind of maintenance heavy. LSVW - hated the phuqing things - initially no comms with equipment lockers between the box and the cab, batteries blew up, went 0-60 eventually in a tail wind with someone pushing. Loading system wasn't too bad - was borrowed off the Unimog. Loved my Unimog - 12 speed manual transmission, 8 forward, 4 in reverse, high wheel base for some mine protection and driving through shite terrain, could go almost anywhere, had a lot of working space in the box and a neat hydraulic assist to get litters up into the various tiers. Loved my Bison, for all its quirks...though the newer variant had better equipment load out, was up armoured and up powered. When the heater was maintained, was comfy in the cold, but if water wasn't drained from the hull, she got cold...used to get stuck in the same places the LAV's I chased around did, so some disadvantages of being wheeled...felt better protected than a 113 though.

My $0.02

 

[Blackadder1916]

The present (?)/the future (?)

First new armoured ambulance arrives in Edmonton

“This is an exciting moment as the modernization of the Armoured Ambulance fleet represents a tremendous force multiplier as we increase our ability to treat, move and communicate on operations at home and abroad.”

www.canada.ca

. . . Cdn Div should receive its full complement of 14 armoured ambulance ACSVs by the end of June 2024. . . .

Once 3 Cdn Div has received its full complement of 14 armoured ambulance ACSVs, they will be distributed to units across the division. Three will be assigned to each of 1 Fd Amb, 1 PPCLI, 2 PPCLI and Lord Strathcona’s Horse (Royal Canadians). Two will be provided to 1 Combat Engineer Regiment.

Still seems like paltry numbers.





I'd be interested in what the standard medical kitting is/will be.

 

[Fabius]

An additional consideration for what medicine on the battle field will look like is changes around the general concept of the golden hour.

Through the GWOT meeting that golden hour involved extensive air medevac to R3 facilities. Obviously for LSCO both the volume of casualties and the threat environment will largely preclude pushing air medevac right to the FLOT.

However meeting the golden hour can be achieved in other ways, primarily by pushing trama surgical teams forward closer to the FLOT.

As this article points out our allies have extensive experience with Forward Surgical Teams, and we have a small capability as well.

Canadian Military Journal

www.journal.forces.gc.ca

 

[KevinB]

FWIW -down here the AMPV has two different Medical "Ambulance" variants - an Evacuation model for 4 litters or 6 ambulatory pateitns- and a Treatment version - that from wealth I have seen is pretty much just a one patient "OR"
To quote their brochure:

Designed to adopt to new survivability technology, the Medical Treatment variant works in tandem with the Medical Evacuation variant to receive and evacuate casualties while providing life-sustaining care to soldiers suffering from lifethreatening injuries. The interior offers a larger space-capacity for medics to maneuver inside the vehicles while treating patients, and increased load capacity to carry more equipment operated on electrical power.
Armed with advanced medical equipment to help soldiers injured in battle, the Medical Treatment vehicle is capable of carrying equipment to conduct damage control resuscitation while awaiting further evacuation from forward operations.
Equipment such as the erectable treatment shelter, medication, vital signs monitor, defibrillator, and refrigerator for storing blood, convert the Medical Treatment into a medical station on the front lines, known as a Forward Aid Station. The full climate control of the vehicle helps to stabilize patient body temperature quickly in varying warfare environments.

https://www.baesystems.com/en-us/product/armored-multipurpose-vehicle-ampv#