Attrition: Medical Care in the Combat Zone


January 5, 2024: Some things never change in Russia and one item is medical care. Russia never was able to establish a nationwide healthcare system and military health system comparable to those found in the west. This was especially true in the military. Russian medical care in combat units, especially in combat, was never very effective or even available.

In the combat zone there was poor or nonexistent medical treatment for the wounded. It was the same for diseases that of the breakout among troops in the combat zone. Russian troops in Ukraine are currently suffering from what is called mouse fever and receiving little treatment. This means a growing number of Russian troops are technically available for service but are in fact disabled by the mouse fever, which Russian military medical personnel have been slow to deal with. In part that’s because this is a new ailment, and the Russian medical community has not yet found a way to effectively deal with it.

It's a different situation with Ukrainian troops, where the army has been quick to adopt western military practices. The traditional military feldsher (medic with practical but no formal medical training) have received more training and better equipment than their Russian counterparts. The results have been dramatic.

About 40 percent of Russian casualties die compared to only 20 percent of Ukrainian casualties because the Russians in this war often get no battlefield medical treatment whatsoever. The Ukrainians eagerly adopted western combat medical practices, which were above average during World War Two and continued to improve after that war. Subsequently western forces have at least minimal battle treatment, largely by getting the wounded off the battlefield to be treated by medics and eventually sent to field hospitals where surgery and other emergency treatment was available. It has long been known that wounded soldiers in freezing conditions died of exposure or shock within about an hour unless they are carried to shelter, but that is not happening for Russian soldiers in this war at all even though it was done somewhat during World War Two. Soviet field medics then were generally women with no medical training whose major job was to crawl out into battlefields with groundsheets, roll wounded soldiers onto those, and then drag them back to an aid station. There are no such Russian female medics in this war so wounded who cannot themselves crawl to a rear aid station generally die. Prospective recruits know this and that’s another reason for avoiding military service.

One of the more amazing, and underreported, aspects of the wars in Iraq and Afghanistan, are the dramatically lower American casualties compared to Vietnam, and previous 20th century wars. The casualty rate in Iraq was a third of what it was in Vietnam. It was even lower in Afghanistan and all subsequent conflicts. Medical care has gotten much better, quicker, and faster. Not only are procedures more effective, but badly wounded soldiers get to the operating table more quickly. Field medics now have capabilities that, during Vietnam, only surgeons had. All this is one reason why the ratio of wounded to killed was 6 in Vietnam, compared to 7.3 for Iraq. In Ukraine, Ukrainian troops benefit from these changes, their Russian adversaries do not.

The fighting in Iraq and Afghanistan has brought about a major change in how the United States deals with combat casualties. The result is that over 90 percent of the troops wounded survived their wounds. That's the highest rate in history. There are several reasons for this. The main one is that medics, and the troops themselves, are being trained to deliver more complex and effective first aid more quickly. Military doctors now talk of the platinum 10 minutes, meaning that if you can keep the wounded soldier, especially the ones who are badly hurt, alive for ten minutes, their chances of survival go way up. Medics have been equipped and trained to perform procedures previously done only by physicians, while troops are trained to do some procedures previously handled only by medics. This skill upgrade is made possible by a number of factors.

First, over the last few decades, there has been continuous development in methods and equipment for emergency medicine practiced by ambulance crews and staff in emergency rooms. These practices were initially slow to be adopted by the military. Two decades ago, because of the fighting in Iraq, it had nearly all been adopted by military medical personnel. This was often due to medics in reserve units often having full time jobs as emergency medical personnel.

As much as combat deaths have been reduced in the last decade, by more than half, there are still some types of wounds for which there is no battlefield treatment, meaning the victim will die before more extensive treatment can be obtained. Chief among these are abdominal wounds, where the abdominal aorta is opened. When that happens the victim bleeds to death in minutes. Now there is a solution for this in the form of a belt that is placed on the abdomen and activated. A bladder inflates which puts sufficient pressure on the abdominal aorta to stop the bleeding or reduce it enough to make it possible to get the casualty to a surgeon.

While tourniquets have been around for thousands of years, these devices only work on limbs. Preventing death from most other rapid blood loss situations was achieved in the last decade with the development and widespread use of powders and granules that could quickly stop the bleeding. First came special bandages like the Chitosan Hemostatic Dressing, more commonly called HemCon. This was basically a freeze dried substance that caused rapid clotting of blood and was incorporated into what otherwise looked like a typical battlefield bandage. It greatly reduced bleeding, which had become the most common cause of death among wounded American troops. This device was a major breakthrough in bandage technology. Over 95 percent of the time, the HemCon bandages stopped bleeding, especially in areas where a tourniquet could not be applied. This did not work when the abdominal aorta was involved. HemCon was followed by WoundStat powder to deal with some of the bleeding that HemCon could not handle. While medics and troops prefer the bandage type device, there are situations where WoundStat, a fine granular substance is a better solution, especially in the hands of a medic. Only the medics got packets, usually two of WoundStat powder. That's because this is only needed for deep wounds and has a theoretical risk of causing fatal clots if it gets into the bloodstream.

WoundStat was but one of many new medical tools for battlefield medicine that greatly increased the effectiveness of the immediate within minutes or seconds, after getting hit, by medical care for troops. This effort consisted of three programs. First, there was the development of new medical tools and treatments that troops could quickly and safely be taught to use. This included stuff like HemCon. Then came the equipping of medics, about one for every 30 or so combat troops with more powerful tools, so that troops were less likely to bleed to death or suffocate from certain types of wounds that are not fatal if treated quickly enough. Finally, there was the Combat Lifesaver program, which more than tripled the number of medics by putting selected soldiers through a 40 hour CLS or Combat Lifesaver course in the most common medical procedures soldiers can perform to deal with the most dangerous types of wounds usually encountered. These CLS trained soldiers are not medics, of course, but they do make available in combat crucial medical treatments. Thus, they are sort of medics lite, which is close enough if you are badly wounded and in need of some prompt medical treatment.

During the last two centuries major wars have tended to produce significant improvements in medical care. This is what has happened in the past decade but in a much accelerated fashion. For example, since September 11, 2001, over two million American troops went off to war and about two percent of them were killed or wounded. Only 12 percent of the 57,000 combat zone injuries were fatal, the lowest percentage in military history. This was largely due to major improvements in dealing with rapid blood loss (as when a major artery is severed) and the increased speed with which complex medical care could be delivered to wounded troops. New medical technologies also made it possible to detect injuries like brain trauma that, in the past, was very difficult to detect and treat.

The Combat Lifesaver course teaches the troops how to do things like inserting breathing tubes and other emergency surgical procedures to restore breathing. The CLS troops have skills most likely to be needed in life-saving situations when a medic is not available. The additional emergency medical training, and new emergency first aid gear, the CLS bag, has saved hundreds of lives and reduced the severity of even more wounds. Enough troops have taken CLS training so that there is one for every 10-15 combat troops and one for every 20 or so support troops on convoy or security duty.

These new developments were also popular with civilian emergency medical services, and many of the experienced combat medics coming out of the military went to work as EMTs or Emergency Medical Technicians, thus increasing the quality of care for civilian accident victims. This was similar to what happened to the EMT field after the Vietnam War, when ambulance crews rapidly evolved from simply transporting accident victims, after a little first aid, to EMTs who could administer procedures that previously only doctors could handle. This followed the experience in World War II, where war demands led to development of mass production of the newly created antibiotics and that led to a revolution in surgery techniques.

Second, there's the high intelligence and skill levels of the volunteer military. High enlistment standards have largely gone unnoticed by most people, but within the military it is well known that combat troops are much brighter than at any time in the past and can handle more complex equipment and techniques. Getting the combat troops to learn these techniques is no problem, because for them, it could be a matter of life and death.

Third, medical teams, capable of performing complex surgery, are closer to the combat zone. These teams, like the medics and troops, have more powerful tools and techniques. This includes things like telemedicine, where you do a video conference with more expert doctors back in the U.S., to help save a patient.

The speed at which wounded troops get treated was called the golden 10 minutes in the 20th century, now that has become the platinum 10 minutes because more effective care can be applied more quickly.

All this is part of a century old trend. During World War II, the golden hour standard of getting wounded troops to an operating table was developed. Antibiotics were also developed at about the same time, along with the helicopter, whose first combat mission, in 1945 Burma, was to recover injured troops. So, these new developments are not anything exotic.

Finally, the military medical community has a track record of success that the troops know about. So, everyone realizes that if they pitch in, chances of survival are good, and they are. In Ukraine the results are startling because Ukrainian troops who are wounded get better battlefield medical treatment and are quickly moved to where they can receive hospital level care. It’s another reason why Ukrainian troops have higher morale and combat capability than their Russian counterparts. The Russian troops often have no professional medical care from medics, or feldsher, while the Ukrainians do. Russian wounded troops who are captured are allowed to let their families know they are alive but injured. Eventually these Russian troops are able to let their families know that they received much better medical care from the Ukrainians that the Russian military could provide.




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