Page 78 - JSOM Winter 2025

FIGURE 4 Resuscitation room. present persistent threats that effectively deny safe and timely
air and surface evacuation routes for medical units. These plat-
forms operate at relatively low altitudes and possess advanced
targeting capabilities, dramatically increasing the vulnerabil-
ity of traditional above-ground medical facilities and medical
evacuation convoys. 17

Consequently, casualty evacuation pathways face prolonged de-
lays, escalating morbidity and mortality rates among wounded
personnel due to delayed surgical intervention. The require-
ment to operate in such an air-denied environment necessitates
medical capabilities resilient enough to function independently
of conventional evacuation chains.

Underground hospital facilities provide a critical solution to
mitigate risks posed by persistent UAS threats. Their ST nature
offers intrinsic protection from aerial observation, targeting,
and direct kinetic strikes. By embedding essential medical and
surgical capabilities underground, these facilities maintain
operational continuity, enabling immediate damage control
FIGURE 5 Operating theatre.
resuscitation and surgery without reliance on air mobility or
surface evacuation assets. This operational model substantially
shortens the interval between injury and enhanced care, thus
directly improving survival rates.

Lessons for the West
Given the evolving dynamics of modern peer-on-peer conflicts,
Western Military medical services must seriously evaluate the
integration of ST medical treatment facilities into future military
doctrine. The current conflict in Ukraine has starkly highlighted
vulnerabilities inherent in traditional above-ground or tent-
based facilities when faced with precision-guided munitions,
drone surveillance, and sustained artillery bombardment. 18–19
ST facilities offer distinct survivability advantages by provid-
ing hardened protection, significantly reducing susceptibility
and a Green Zone for minor injuries and primary health care. to aerial and indirect fire threats. Such facilities ensure con-
It has central access and egress routes capable of receiving an tinuity of critical medical operations even when conventional
ambulance. evacuation pathways are compromised or denied. Integrating
ST facilities into military medical doctrine aligns operational
medical capability with modern battlefield realities, enhancing
Conclusion force protection, reducing casualty evacuation timelines, and
The ST CSP is fixed and does not fit the manoeuvrist approach, ultimately improving patient outcomes.
however, for the AFU fighting a war dominated by indirect
fire and aerial threats, this capability provides a gold standard The complexity inherent in establishing functional ST med-
solution to protect medical personnel as far forward as possi- ical treatment facilities necessitates active collaboration be-
ble, whilst reducing the evacuation time from POI to overall tween defense medical services and both military and civilian
‘knife to skin’ time. This is evidenced by anecdotal reporting of engineering specialists. Cross-disciplinary partnership is es-
the high survivability rate of all casualties reaching the facility, sential, bringing together the clinical expertise necessary for
combined with 80% of casulaties with ‘high-resource burden, operational effectiveness with the engineering and structural
Low-suvival probability’ injury patterns surviving to the next knowledge required to safely design, construct, and maintain
echelon of care. underground medical infrastructure.

This is just one option for medical force protection in this bat- Collaborative efforts should include military engineers familiar
tle environment and it signifies the doctrinal shift required for with battlefield constraints and civilian specialists who possess
medical support to survive and function. Buildings of oppor- advanced geotechnical, structural, and systems engineering ca-
tunity and other alternatives to tented facilities that still fit the pabilities. Early engagement and joint planning efforts would
manoeuvrist approach must continue to be considered, how- ensure comprehensive design considerations covering stability,
ever, in contemporary warfare, the widespread deployment ventilation, power generation, waste management, and environ-
of Unmanned Aerial Systems (UAS) significantly constrains mental control systems. Such integrated collaboration would
near-airspace operations, profoundly impacting traditional ca- enable the Western Military medical services to rapidly adapt
sualty evacuation (CASEVAC) methods. UAS platforms, par- and effectively implement ST medical facilities, significantly
ticularly loitering munitions and armed reconnaissance drones, strengthening operational medical resilience in future conflicts.

76 | JSOM Volume 25, Edition 4 / Winter 2025