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The Sub-Terranean Casualty Stabilization Points

John Miles, MBE, MBChB, MRCGP, DMMC, DipIMC *;
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Andrew Hamer, MBChB, MRCGP, DMMC, DipIMC ; David Ferraby, BSc (Hons) MCSP 3

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ABSTRACT
The evacuation timelines of Ukrainian casualties through (AFU) OPCP can reportedly take anything from minutes to
the Operational Patient Care Pathway (OPCP) vary widely, days from point of injury (POI) to the first surgical facility. 1
ranging from minutes to days. Western Military reliance on
air evacuation models has proven inefficient in the current Western Military reliance on air evacuation models in recent
conflict, dominated by sophisticated air defense and elec- conflicts provided an efficient and well-practiced pathway of
tronic warfare. This paper explores the adaptation of medi- rapid (air) evacuation to damage control surgery within 1–2
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cal support in static warfare, focusing on the development of hours . This concept has been proven near impossible in peer-
Subterranean Casualty Stabilization Points (ST CSP) by the on-peer conflict, with a contested air environment dominated
Armed Forces of Ukraine (AFU). These facilities provide dam- by sophisticated air defense and electronic warfare, creating
age control resuscitation and damage control surgery close to the iron dome effect . It raises the question of what can be
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the front lines, significantly reducing the time from injury to done to enable the right medical care in the right place and in
surgery. The ST CSPs, built with enhanced protection, repre- the right timeframe.
sent a paradigm shift in military medical doctrine, offering a
gold standard solution for casualty care in a contested envi- Historical Context
ronment. This study highlights the need for Western militaries
to consider similar adaptations to ensure the survivability of Subterranean (ST) hospitals first emerged during World War I,
medical force elements in future conflicts. exemplified by the Wellington Quarry beneath Arras, France,
providing protection from artillery fire. World War II saw fur-
• The Russia–Ukraine conflict has demonstrated the diffi- ther expansion of underground medical facilities, notably in
culty an air-denied environment poses for medical evacu- London’s underground system during the Blitz and extensive
ation (MEDEVAC) and the requirement this will drive for facilities built in Malta. These offered resilient, protected
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placing surgical stabilization facilities close to the front line medical care amid sustained aerial bombardments. The Viet-
of troops (FLoT). nam War witnessed substantial use of STmedical infrastructure
• Artillery and drone munitions would preclude tented and by the Viet Cong within the Cu Chi tunnels. Despite rudi-
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other traditional forward solutions. mentary equipment, these facilities functioned effectively un-
• This paper presents ST CSP as an option that enables dam- der heavy bombardment. Contemporary examples in Ukraine
age control resuscitation and surgery to be provided in oth- echo historic precedents but incorporate advanced technology
erwise prohibitive tactical environments. to enhance effectiveness, further underscoring the value and
adaptability of ST medical facilities in modern conflict.
Keywords: military personnel; armed conflicts and warfare;
emergency medicine; resource-limited settings; emergency A Novel Solution
medical services; trauma surgery; triage
Western war-fighting doctrine is built on manoeuvre, joint
integration, technological overmatch and mission command,
aiming to achieve decision through tempo and precision rather
Introduction
than attrition. The Ukraine war has challenged these assump-
The evacuation timelines of Ukrainian casualties through the tions by demonstrating a transparent, attritional battlefield
Operational Patient Care Pathway (OPCP) are reported to vary dominated by drones, electronic warfare, fortifications and in-
widely across the battle space. The Armed Forces of Ukraine dustrial capacity, forcing Western forces to rethink survivability,
*Correspondence to John.miles446@mod.gov.uk
1 Maj John Miles is a doctor affiliated with the Defence Medical Services, UK. Maj Andrew Hamer is a doctor affiliated with the Defence Medical
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Services, UK. Maj David Ferraby is a medical planner affiliated with Defence Medical Services, UK.
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