Page 121 - JSOM Winter 2025

impact and optimal management strategies for hypocalcemia prior to D-Day—we must not let that happen again and
in trauma care. stockpile sovereign capability stores for war now.
• Death: ‘Sing your death song and die like a hero going
Reference home’. The mean U.K. blood requirement for acute combat
1. Dupuy C, Martinez T, Duranteau O, et al. Comparison of the lethal injured soldiers with bilateral leg amputations in Afghani-
triad and the lethal diamond in severe trauma patients: a multi- stan was 66 units. The maximum was 94 units of packed
center cohort. World J Emerg Surg. 2025;20(1):2. doi:10.1186/ red cells, 76 units of FFP, 12 units of platelets, 8 of cryopre-
s13017-024-00572-5
cipitate and 3 units of fresh whole blood—a total of 193
Run, Hide, Disappear & Fight to Save: units of product. This will not happen again. We need to
Prolonged Field Care and Resuscitative Surgery make early futility decisions as early as 4 or perhaps 2 units
on the Future Battlefield of product. In this way more can be saved. We should not
Colonel Paul Parker fear giving a wounded warrior a „good death.“
• Deny: The use of fast drone CASEVAC and resupply sys-
Any surgical team or medical facility on the future battlefield tems allows surgical resuscitative care to be potentially
that is neither hidden nor protected or defended will be a pri- moved to other countries (e.g., Odessa to Chisinau in Mol-
ority soft target and destroyed within minutes. The idea that dova in 21 minutes). This will be our future—no risk at
a green canvas tent or soft skinned vehicle covered or painted dispatch, only the casualty at slight risk on nap-of-the-earth
with a Red Cross (The “Dread Cross”) will offer any protec- return. Care can also be delivered en route.
tion under the Geneva or other Conventions of ‘Future War’ • Delegate: Experienced surgeons and anesthesiologists take
whatsoever is over. The Red Cross is now a target identifier. 18–20 years to train. They are high-value targets and no
Killing a medic or doctor is felt to be like killing 100 soldiers. country has enough of them. They are best sited in high-
What are our options? volume, well-resourced Damage Control Phase III centers
• Disperse and Deceive: It will be better to have 25 small well behind the frontlines. This is not cowardice, just com-
stabilisation points / Role 2 facilities along the front, dis- mon sense. Recognising that no U.K. or U.S. casualty from
guised as worthless or very low value targets, such as wood recent conflicts that had a named in-torso vessel injury
carrying trucks, rusty shipping containers or Aldi and Lidl survived, we must be pragmatic. Those that survive have
lorries. small intestinal bleeds and leaks with moderate kidney and
• Disappear: The Vietnamese were adept at this during their hepatic injuries. AAJTs and blood transfusion can buy time
war, either operating under primary canopy jungle or in but in-torso contamination limitation with 4- quadrant
cave complexes, such as Hang Quân Y Cave, impervious packing, extremity vascular control, pelvic packing, de-
to American bombing. The ‘Hospital in the Rock’ was con- bridement, stabilisation including external fixation and
structed under Buda Castle in Budapest and treated at one amputation using paired single syringe anaesthesia provid-
time over 600 German soldiers during the siege of Budapest ers who are not physicians is an attractive option.
in 1944/1945. Similar facilities were created in Jersey and • Develop: We will call this the 18Ω program. It will cover
Guernsey during their occupation in World War II. Many advanced pain management, austere intensive care and pro-
Ukrainian R2 hospitals are now completely dug in behind longed hold. We will take experienced physician assistants,
the frontline. Underground car parks and shopping centers 18-D/68W/NSOCOMs, and CMT1/paramedics (those who
will be useful. can play a musical instrument are more easily trained as
• Declare: The Israeli ‘Shining Star’ Hospital opened in surgeons) and prior to the conflict will have the luxury of
Mostyska just after the second invasion of Ukraine. It a 6-month training program. This will include didactic lec-
declared its location to the enemy, this offered some pro- tures, perfused cadaver and animal labs, and clinical place-
tection due to the more unique nature of the relationships ments. Once the war starts, this will have to reduce to 6
between that country and the enemy. It closed 6 weeks later weeks. We are already, in the U.K., training ‘relatively ju-
and after recent events in Iran with their bombing of the nior’ Ukrainian surgeons on our Definitive Combat Surgery
Soroka Hospital in Beersheba it shows how tenuous and Courses (DCSC). The earlier the decisions are made to em-
fragile such an arrangement can be. brace risk and up-skill, empower and train our medics, the
• Discipline: Modern ventilators and monitors, diathermy more time we have to teach and improve survival outcomes
machines and ultrasound probes all emit significant 3G in the war to come.
and RF targetable radiation. The same holds true for the
ubiquitous Apple Watches of officers and the Garmin Fenix Multiple Organ Failure Following Severe
8’s of soldiers. Battle Injuries During Recent Conflicts: A French
• Defend: Physical deterrence is a significant option. Oer- Retrospective Cohort Study
likon’s Skynex/Phalanx for structures and the Trophy/ Pierre-Louis Quere, Johan Schmitt, Intensive Care Unit,
Windbreaker active vehicle protection for ambulances of- Military Teaching Hospital Sainte Anne, Toulon, France
fer significant active protection. Passive protection even for Introduction: Improvements in combat casualty care have in-
Main Battle Tanks is now seemingly useless. creased survival rates, but these patients are at particular risk
• Delay: Medical care on the future battlefield will not be of developing multiple organ failure (MOF). We investigated
delivered by physicians—all medics must be able as a bare the incidence and severity of MOF in a cohort of severe com-
minimum to administer antibiotics, tranexamic acid, and bat casualties.
blood; deliver effective long-lasting pain medication; and
independently transfuse blood and plasma. Tourniquet Methods: This retrospective study included all on-duty French
conversion on all sites, abdominal, junctional or extremity, land army war casualties with a severe combat injury requiring
is key. Penicillin ran out for the British in World War II intensive care unit admission during 2009–2023. Demographic

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