Page 77 - JSOM Winter 2025

mass, sustainment and how manoeuvre can be achieved under FIGURE 1 Construction of an ST CSP. 10
constant surveillance and contested conditions. 7–8
The Western Military manoeuvrist approach applies indirect
action to undermine the enemy’s will to fight rather than con-
9
fronting their strengths directly. However, against a near peer
threat, in the era of drone warfare under the iron dome, there
is a requirement to consider how one would provide medical
support during static warfare with a significant aerial threat.
One key innovation is the development of ST Casualty Stabili-
zation Points (ST CSP), enabling timely resuscitative and surgi-
cal interventions under protected cover near the front lines. 10,11
The Ukrainian Operational Patient Care Cycle sees patients
move from POI, to an evacuation point (EP) or casualty col-
lection point via any means possible, then to a CSP which
provides Damage Control Resuscitation and Damage Control
Surgery. The AFU distribution of casualties focuses on the flow
of patients to areas where the treatment can be delivered most SADCHAP = size, access, defence, concealment, hardstanding, accom-
efficiently with the redirection of casualties depending on their modation, position.
medical requirement. This is undertaken through a networked FIGURE 2 General medical ward.
health system which triages patients based on medical need. To
mitigate the aerial threat, several Ukrainian medical treatment
10
facilities have moved into the ST domain (Figure 1). This is
a novel example of the changing medical doctrine of the AFU,
and has enabled reduced time from POI to Damage Control
Surgery due to ST CSP proximity to the forward line of troops.
Establishing ST hospitals requires multi-disciplinary collab-
oration, including civil and geotechnical engineers, military
strategists, medical planners, and mechanical and electrical
engineers. One must apply the planning principles of Medical
Treatment Facility location selection but also consider drain-
1,2
age to avoid flooding and maintain sanitation, ventilation to
ensure air quality and infection control, power supply, waste
removal and temperature control.

ST CSP facilities substantially mitigate threats such as artillery
shells, drone strikes, and aerial bombardments. The facilities
provide inherent protection from direct strikes, fragmentation, FIGURE 3 Intensive care unit.
and blast overpressure. Reinforced construction, compartmen-
talization, and secure ingress and egress routes significantly
enhance personnel and patient survivability and the opera-
tional patient care cycle (OPCC).

By pushing damage control surgical capability as far forward
as the Role 1 space, made possible by the enhanced protec-
tion provided by ST facilities, one can see a paradigm shift
from the conventional Western Military operational patient
care pathway, whereby Role 1 care is limited to damage con-
trol resuscitation. 12–14 In future warfare dominated by drones
and long-range strategic fires, this ST damage control surgical
capability provides one solution to initiate surgery as far for-
ward as possible. In a battlespace with constrained movement
at the POI—thus delaying casualty evacuation—this model
enables a degree of bridging that evacuation gap to reduce the intelligence surveillance and reconnaissance. It was built during
time from injury to damage control surgery, and ultimately the warmer months when the ground was firm and dry. The
reducing morbidity and mortality. 16 soil was removed, with structures being emplaced and then
backfilled to conceal and protect the facility. It is built with six
The ST CSP is the gold standard of dug-in medical facilities for expanded steel bunkers, each 7.6m long and 2.5m wide, which
the AFU in terms of structural integrity and protection from form the foundation of the hospital below ground and is built
known threats. with a combination of wood, steel, and concrete. There is
11
an additional dug-in technical area which contains generators
The CSP pictured (Figures 2–5) is the first of its kind for the for power supply. It is divided into three sections, a Red Zone
AFU. It was mainly dug at night to avoid detection from for higher priority patients, a Yellow Zone for lower priority,

Sub-Terranean Casualty Care at the Front | 75