Medical Challenges in Underground Warfare

Introduction: Throughout history, underground systems have served military purposes in both offensive and defensive tactical settings. With the advance of underground mining, combat tactics, and weapon systems, providing medical support in the subterranean battlefield is a constantly growing challenge. This retrospective cohort study describes the Israeli Defense Force (IDF) Medical Corps experience with treating casualties from underground warfare, as recorded in the IDF Trauma Registry. Methods: A retrospective cohort study of all casualties engaged in underground warfare, between the years 2004-2018. Medical data were extracted from the IDF Trauma Registry and tactical data were obtained from operational reports. An expert committee characterized the most prevalent challenges. Recommendations were based on a literature review and the lessons learned by the IDF experience. Results: During the study period, 26 casualties were injured in the underground terrain. Of casualties, 12 (46%) due to blast injuries, 9 (35%) were due to smoke inhalation, and 5 (19%) due to crushing injuries. All were males, and the average age was 21.6 years. Ten (38%) were killed in action (died before reaching a medical facility). All 16 casualties reaching the hospital survived (Table I). The expert committee divided the most common challenges into three categories-tactical, environmental, and medical. An overview of medical response planning, common injuries, and designated combat casualty care are discussed below. As in all combat casualty care, the focus should be on safety, bleeding control, and rapid evacuation. TABLE I. Casualties Characteristics Smoke Inhalation Crush Injury Blast Injury Total Age (mean) 22.4 21 21.2 21.6 2000-2010 2 (22%) 3 (60%) 9 (75%) 14 2010-2020 7 (78%) 2 (40%) 3 (25%) 12 Single casualty event 1 (33%) 3 0 4 Multiple casualty event 2 (67%) 1 (33) 12 (100%) Air Evacuation 0 1 (20%) 2 (17%) 3 Penetrating Injury 0 0 9 (75%) 9 Blunt Injury 0 5 (100) 3 (25%) 8 Injured body region Head 0 1 (20%) 1 (8) 2 Torso + Pelvis 0 2 (40%) 2 (17%) 4 Limbs 0 1 (20%) 5 (42%) 6 Intubation/Coniotomy 0 0 2 (17%) 2 Fluid Resuscitation 1 (11%) 1 (20%) 2 (17%) 4 Survived 7 (78%) 2 (40%) 7 (58%) 62% Total 9 5 12 26 Conclusion: To plan and provide medical support, a thorough understanding of operational planning is essential. This manuscript presents the evolution of underground warfare, tactical and medical implications, environmental hazards, and common casualty care challenges.