KaLiSCOPE

Catchy phrase? Thought-provoking idea? Another one of those I’ve come up with, at some point after February of 2022… Not surprisingly, it’s been “borrowed by others”, but the primary goal of this post is far more noble than the authorship claim itself.

As the next war continues to encroach towards the Eastern NATO border, it is necessary that we, as medical community, discuss a number of complex topics. It’s nothing we were taught in medical training. It’s not part of the civilian healthcare curricula, nor has it been updated in the military ones. It’s knowledge I’ve been gaining at war since 2022…

Both patient care, and your own life will likely depend on being well-grounded in the reality of wartime medicine, so let’s start with “where”…

Literally hidden UNDERground…

Underground locations have long offered refuge for the ill and injured at wars. Makeshift or purposefully built they housed both military and civilian healthcare facilities in any wartime settings. Since World War II we have made astronomical progress in medicine, including unprecedented advancement in combat casualty care. We have founded “peace-lobbying” organizations and established laws of armed conflicts against targeting of medical personnel. Yet little has been innovated in context of civilian hospital design and forward military care to offer scalable or easily deployable infrastructure for underground healthcare operations.

What we have is NOT what we may need…

Let’s face it! Many modern hospitals have stunning ICU’s (intensive care units) on the second floor and mind-blowing operating rooms on the 3rd… With spacious parking lot and technical rooms at the underground level at most! Few, if any, have a feasible plan for rapid relocation of healthcare operations below the surface in case of wartime destruction.

Things aren’t better in the military medical sector either. We (i.e. NATO) keep rehearsing for the last war, and continue to exercise care delivery in open spaces, and tents or containers. The industry keeps bragging about their newest versions of these surface death traps, while they should innovate below the ground solutions.

What Geneva Convention?!

Let’s look at the Ukrainian experience! Geneva Convention? What Geneva Convention!? Targeting of medical assets is their daily reality. Looking at the WHO official reporting system for attacks on healthcare you get it immediately why red cross is now called the “dread cross”. Since February of 2022 more than 2400 attacks have been recorded in Ukraine. Civilian or military, treating adults or children… It didn’t matter – russians intentionally damaged or destroyed them all. Given the prospects of war in Europe, we must note that neither fancy hospital towers nor the current NATO concepts of forward medical facilities are going to serve us well.

Adapting what’s out there... Both civilian and military?

Moving medical care below the surface is not as simple as relocating into a hospital basement, or a dugout in the proximity of combat. In Ukraine, it has become common practice to adapt the existent infrastructure for underground medical purposes, both military and civilian. In case a catastrophe strikes, some hospitals have transformed their old soviet bomb shelters or other such locations into inpatient wards. Despite extensive renovations, all such facilities seem to struggle with poor access, moldy spaces due to inadequate ventilation, or outdated sanitary set-ups. Things are even more challenging for the military in forward locations. Many of the adapted buildings, even if they were once designed for medical, are not best fitted for such forward facilities. They may lack critical sanitary infrastructure, they may not be easily accessible, or access may pose operational security risk. Glass windows need to be blacked out and protected from shatter. Down in the basements, walls and ceilings need to be sealed off with some sort of plastic to prevent dust setting. Air circulation is close to non-existent, and there are too few safety exits in case of structure collapse. As a result, personnel may be trapped, injured or even killed. And valuable medical equipment may be broken beyond repair. So while this concept is viable and broadly utilized, it surely has lots of issues with functionality, safety and access.

The better solutions?

There are obviously better ways to do it! Although more costly and time-consuming in advance, purposefully designed facilities for underground healthcare operations would ultimately save more lives.

In terms of mission-oriented design nothing seems to beat the Rambam Fortified Underground Emergency Hospital (FUEH) in Israel. This level 1 trauma center housed at 3 underground floors, offers full spectrum of patient care services spread over 2000-beds. Impressive? To say the least! What’s even more mind-blowing is their < 72 hours set-up time to become fully operational. In response to recent attacks it actually took them 15!!! The facility can withstand conventional, chemical, and biological attacks, ensuring continued operations even under adverse conditions. And during peacetime it serves as an underground parking lot.

When it comes to forward military facilities, effective solutions depend on the combat environment. What’s shown to work in the steppes along the Ukrainian frontlines, would not be as applicable to urban or mountainous terrain. Yet one common denominator remains: it’s a suicide mission to deploy any kind of red-cross-marked surface infrastructure, when the evil eyes of enemy drones keep watching you 24/7. Being well-grounded in reality of modern day warfare means literally going UNDERground.

Stealing other people’s creative ideas is NOT the highest form of flattery. It’s called intellectual property (IP) theft: there are laws against it, and there are easy ways to prove it! It’s particularly disturbing when colleagues knowingly commit this violation! This ain’t honorable nor even acceptable, especially during war…

Kasia Hampton, MD