MIND THE GAP - MITIGATE THE DIP MEDICAL ANALYTICS & RECOMMENDATIONS FROM THE UKRAINIAN FRONTLINES
- May 7
- 7 min read
Mikhailo NIKOLAIEV
PHD, Head of the forward surgical team of Zaporizhzhia Zilitary Hospital
Roman KUZIV
Lieutenant Colonel of the Medical Service
Commander of the Military Medical Clinical Center of the Eastern Region
Currently, NATO alliance is not only IN THE DIP of the interwar period, but it is also facing an UNPRECEDENTED WIDENING OF THE GAP in their medical capabilities. “The next war” is already being fought without their actual involvement.
It is a well-recognized phenomenon, known as THE WALKER DIP, that periods of time between any major armed conflicts lead to significant decline in the level of medical readiness within any armed forces. With cessation of combat activities, and force demobilization, strategic commanders lose their emphasis on the medical capabilities. Any lessons learned are insufficiently captured in training and doctrine, and the overall institutional experience drastically declines.
Hence the initiative of the ongoing series named “Medical Analytics & Recommendations From the Ukrainian Frontlines”.
It is aimed at stimulating rapid military medical knowledge translation from the russo-Ukrainian war.
Let us close this gap jointly, and elevate NATO from the potentially catastrophic dip, while working together to save more lives on the battlefields of Ukraine.
ANALYSIS 1: FPV-DRONE INJURY PATTERNS IN UKRAINIAN COMBAT CASUALTIES
TIMEFRAME | 01/JAN/2024 - 30/SEP/2024 - Period of relatively “low” intensity of combat. |
LOCATION | Zaporizhzhia Region - Eastern Ukraine. |
GIST | JAN-SEP 2024 - STEADY INCREASE in the number of combat casualties injured by the FPV drone strikes with 3.6% KIA (killed-in-action) rate - 26.3% of all combat-related deaths. Aside from strategic & tactical implications - impact on e.g. combat casualty care, combat medical training or ballistic protection research. |
At the battlefields of the russo-Ukrainian war both sides of the conflict extensively utilize FPV (First Person View) drones in combat operations. As an element of modern tactics they are being deployed at an unprecedented rate in the reconnaissance missions, and to target the enemy when armed with explosives. Due to complexity of warfare, their role has increased especially in settings where traditional warfighting measures have limitations, and direct fire control increases the likelihood of being hit. Drones are cheap, small, and easily steered by the unexposed ground operators. Hereby we should note that modified MAVIC-type drones armed with grenades or other explosive devices are also utilized broadly.
Important notice:
MORE DRONE-INJURED 3.6% KIA 26.3% OF ALL DEATHS
ANALYSIS 1: FPV-DRONE INJURY PATTERNS IN UKRAINIAN COMBAT CASUALTIES
As the war continues, FPV drone utilization increases, and so does the number of the drone-injured. Having noted a steady increase of such injuries in the Zaporizhzhia Region, we analyzed the injury patterns among ALL the service members who presented to our medical assets ALIVE from 01/JAN through 30/SEP of 2024. Other data shows that 3.6% of the injured die immediately on the battlefield, which constitutes 26.3% of all the combat-related deaths. Aside from strategic and tactical implications, conclusions from this analysis may have impact on medical planning and logistics, combat casualty care delivery, training design and ballistic protection research.
Below you can find the following analytics:
Prevailing injuries by anatomical site;
Complex anatomic pattern of injury: 2 anatomical sites;
Complex anatomic pattern of injury: 3+ anatomical sites;
Injury severity grading;
Other analytics such as incidence of burns, acubarotrauma*, poisonings, etc.
Important notice:
Term ACUBAROTRAUMA (ABT) is very widely utilized in the Ukrainian medical records and professional literature. It is most commonly defined as injury to the inner ear (hearing and vestibular apparatus) caused by the blast wave. Diagnosis requires otolaryngological expertise. In the English speaking literature it would correspond with the “(primary) blast injury of the ear” (ICD-10 code S09.31).
MAIN ANALYTICS: PREVAILING INJURIES BY ANATOMICAL SITE
ANATOMICAL SITE | % |
HEAD & NECK | 21.88 |
LOWER EXTREMITIES | 19.33 |
UPPER EXTREMITIES | 14.36 |
CHEST/UPPER BACK | 11.14 |
SOFT TISSUES** | 6.04 |
ABDOMEN/LOWER BACK | 5.37 |
PELVIS/BUTTOCKS | 1.34 |
ISOLATED ACUBAROTRAUMA* | 19.46 |
INHALATION INJURY | 1.07 |
TOTAL | 100.00 |
MAIN ANALYTICS:
45.9% COMPLEX PATTERN - 2 ANATOMICAL SITES
ANATOMICAL SITE | % |
UPPER EXTREMITIES | 13,96 |
LOWER EXTREMITIES | 9,8 |
CHEST/UPPER BACK | 6,58 |
ABDOMEN/LOWER BACK | 5,23 |
SOFT TISSUES | 4,43 |
HEAD & NECK | 3,89 |
PELVIS/BUTTOCKS | 2,01 |
TOTAL | 45,9 |
EXAMPLE OF HEAD (OCULAR) INJURY
MAIN ANALYTICS:
21.07% COMPLEX PATTERN - 3+ ANATOMICAL SITES
ANATOMICAL SITE | % |
LOWER EXTREMITIES | 7,52 |
UPPER EXTREMITIES | 3,09 |
SOFT TISSUES | 2,95 |
CHEST/UPPER BACK | 2,42 |
ABDOMEN/LOWER BACK | 2,01 |
HEAD & NECK | 1,88 |
PELVIS/BUTTOCKS | 1,21 |
TOTAL | 21,07 |
MAIN ANALYTICS:
INJURY SEVERITY GRADING
SEVERITY | % |
MILD | 48.90 |
MODERATE | 40.11 |
SEVERE*** | 9.75 |
SEVERE (INTUBATED) | 1.10 |
TOTAL | 100,00 |
*** Requires intensive care
SPECIAL ANALYTICS: PRIMARY BLAST INJURY OF THE EAR (ACUBAROTRAUMA)
ACUBAROTRAUMA - OF ALL PATIENTS | % |
OVERALL INCIDENCE | 45.43 |
WITH TYMPANIC MEMBRANE (TM) PERFORATION | 15.17 |
WITHOUT TM PERFORATION | 29.26 |
AS ISOLATED INJURY | 19.46 |
ACUBAROTRAUMA - ALL CASES | % |
WITH TM PERFORATION AS ISOLATED INJURY | 13.60 |
WITHOUT TM PERFORATION AS ISOLATED INJURY | 30.21 |
WITH TM PERFORATION IN INJURY COMPLEX | 20.54 |
WITHOUT TM PERFORATION IN INJURY COMPLEX | 35.65 |
TOTAL | 100.00 |
SPECIAL ANALYTICS: OTHER
SUMMARY OF FINDINGS
Drone-injuries are a steadily growing threat to military service members, including medical personnel, in the ongoing war in Ukraine.
Even in the well-trained units, 3.6% of the combatants injured in drone attacks die on the battlefield.
Drone-related deaths constitute 26.3% of all combat deaths.
Nearly half of the drone-injured (45.4%) have evidence of the primary blast injury of the ear (acubarotrauma). In 19.46% it comes as an isolated injury. Given symptoms of blast injury to the ear may overlap with TBI symptoms, such high incidence of these injuries creates a new diagnostic conundrum, with significant strategic and tactical implications for the combatant commanders.
Looking globally at the anatomical sites - head & neck zone is most commonly injured (21.8%). This lets us conclude about the significant susceptibility of these areas, despite use of military grade helmets.
Extremity injuries are also a major issue, limiting mobility and combat readiness of the service members. The incidence of lower and upper extremity injuries is 19.3% and 14.3% of cases respectively. This indicates poor protection from the current threat.
Chest and upper back get injured in 11.14% of cases, despite standard body armor, which does not appear to offer sufficient protection.
RECOMMENDATIONS: BALLISTIC PROTECTIVE GEAR
There is a need to reengineer tactical protective gear. Current models of helmets or ballistic vests were designed to protect primarily from gunshot wounds (GSW). GSW’s constitute less than 2% of the overall injuries on the battlefields in Ukraine.
HEAD AND NECK
a. Blast injury transmitted through an unprotected ear canal may cause significant neuropathological changes in the brain, i.e. TBI - tactical hearing protection is an absolute must in the setting of drone warfare.
b. Helmets with facial and occipital protection would be beneficial - motorcycle-like helmets which do not limit visual perception of the warfighter, and do not lead to rapid overheating would be advisable.
c. Protective elements for the neck (cervical ballistic collars) should be added with the same seasonal recommendations as above.
EXTREMITIES - utilization of gear made of light-weight “kevlarized” materials, which do no limit mobility, and do not lead to rapid body temperature elevation, but protect from minor shrapnel would be advisable.
PELVIS AND BUTTOCKS - inguinal ballistic inserts should be used routinely, as most injuries to these areas are severe.
STANDARD BODY ARMOR, both design and materials require an update. Given trunk constitutes 36% of the total body surface area, probability of injury is high. Therefore lateral ballistic (Gen2) protection of the chest, abdomen and back should be added.
To maximize on the effectiveness of utilization, regular training on the correct use of personal ballistic protection should be conducted. Surveillance of gear utilization would be advisable.
RECOMMENDATIONS: (MEDICAL) TRAINING
There is an urgent need to update military (medical) training protocols. As evidenced by a large number of visuals shown in the open media sources, even today, drone threat is not sufficiently accounted for in the training scenarios across NATO and partner nations. Many (medical) scenarios are still played out in an open terrain, without proper consideration for the surveillance and/or assault drones that may hover nearby. Given both drones and mines may be present simultaneously, team movement in such an environment is an entirely new skill that must be mastered - obviously, none can look upward and downward at the same time.
Drones should be routinely utilized in any training scenarios in order to promote threat awareness and appropriate patterns of conduct in hostile environments. It is not sufficient to verbalize that drones are “present”. They should be physically utilized in the training area.
Medical personnel should be trained on:
How to signal and communicate with a friendly drone operator. Drone guidance is often utilized as a protective measure in a hostile environment. Such a friendly drone operator should be regarded as a “guardian angel”, and one must know how to communicate with them. This is an entirely new skill that must be mustered by any personnel in the combat settings.
Different anti-drone protection measures.
Modern combat casualty care training scenarios should include simulated drone attacks (“drone paintball of sorts”) and drone injuries. Small balloons with colored fluid or other non-dangerous objects could be applied.
RECOMMENDATIONS: ANTI-DRONE PROTECTION AND OTHER
Our data is mined from an operational tool that we designed to track the whereabouts of our injured and ill service members in real time. They are entered into our system at the level of role 1. This design is not equivalent to the U.S. Department of Defense Trauma Registry (DoDTR), but with NATO partner support it could be possibly upgraded and developed.
Comprehensive post-mortem examinations are not routinely performed on all the combat-injured in Ukraine. Development of such capability in collaboration with the NATO partners would help identify vital lessons in military medicine.
Given constant threat to anyone in a hostile environment, all military personnel should be familiar with the different layers of anti-drone protection measures. Everyone must know the basic principles of how they work, and how to use them.
It would be advisable to train all military personnel on the utilization of individual mechanical anti-drone weapons. Such have already been developed and are utilized as a last resource. Net-containing “bullets” are fired at an incoming drone from about 25-50 m distance. Drone propellers get tangled into the net rendering it immediately inoperable. Visual contact with a drone is a must.
Hunting rifles have also been used with success to shoot the drones down.
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