Several videos have emerged this week, showing Bradley Fighting Vehicles successfully taking on advanced Russian T-90 tanks.
From Special Kherson Cat on Twitter, video of Bradley IFV vs T-90 in Avdiivka
TALES FROM A PARAMEDIC, PILOT, CAVER, and FIREFIGHTER, WHO MEET IN ANTARCTICA, AND GO ON TO HAVE MANY ADVENTURES IN NEW ZEALAND, TONGA, FIJI, VANUATU, WEST AFRICA, AND UKRAINE. . . . . . . . . . . . . . . Structural Firefighting/ARFF/Joint Antarctic Search and Rescue Team at McMurdo Station Winfly- Summer- Winterover. Sailing a 37' Tayana sailboat in the South Pacific. Ebola Response. Wildland firefighting. War Medic in Ukraine.
Several videos have emerged this week, showing Bradley Fighting Vehicles successfully taking on advanced Russian T-90 tanks.
From Special Kherson Cat on Twitter, video of Bradley IFV vs T-90 in Avdiivka
Kh-47 Kinzhal hypersonic air-launched ballistic missiles, NATO name "Killjoy", entered service in 2017, design based on the older Iskander missile, uses standard ballistic missile technology at greater speeds. After launch, the missile rapidly reaches cruising speeds of Mach 4, and up to Mach 10 on a downward trajectory. Maneuverable, erratic flight path. Originally touted as "impossible to intercept" by Russia, Kinzhals have been used extensively in Ukraine, and a significant proportion of them were successfully shot down by Patriot air defense systems in 2023. They have also proven to be fairly inaccurate. Image from By kremlin.ru, CC BY 4.0, https://commons.wikimedia.org/w/index.php?curid=68926303
Kaliber cruise missile, in service 1994, some models are capable of a supersonic terminal sprint, traves at ~70' over water, or ~150-350' over land, uses inertial guidance +terminal radar or satellite guidance,
Iskander mobile ground-launched, short-range hypersonic ballistic missile, NATO name "Stone", first launched in 1996, as a replacement to the SCUD missile, uses inertial guidance or GPS, depending on model, can be re-targeted midflight, uses evasive maneuvers and decoys during terminal flight, travels at an altitude of 20,000-160,000 feet. Used in Syria, Georgia, Nagorno-Karabakh, and Ukraine wars. In the summer of 2023, an Iskander was used to destroy Ria Pizzeria, a restaurant in Kramatorsk, Ukraine, frequented by journalists, aid workers, and military members. The famous Ukrainian writer Victoria Amelina was killed, along with a pair of 14-year-old twin sisters, and 10 others. Dozens were injured.
Image from Vitaly V. Kuzmin - http://www.vitalykuzmin.net/Military/ARMY-2016-Demonstration/, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=52213498
Kh-101 / Kh-555 / Kh-55 family of air-launched subsonic cruise missiles, Nato name "Kent", in service 1983, inertial guidance with terminal radar/terrain map, capable of cruising at tree-top level, the original Kh-55 ran on a Ukrainian-made Sich motor, used in Syria and Ukraine wars
Kh-22 "Storm" missiles. NATO name "Kitchen". Large, long-range anti-ship missile developed in 1962. Climbs to either 89,000' (high-altitude mode) or 39,000' (low-altitude mode), then hits top speed while dropping towards target. Guided by radio altimeter and gyroscope-stabilized autopilot. A 1,000kg shape-charge load results in a 16' wide, 40' deep hole. First combat use was in May of 2022 in Ukraine. Use against targets in civilian areas of Ukraine has been criticized due to low accuracy. Image by By Антон Бородин - Музей авиационной техники, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=10658517
Kh-59 "Ovod" or "Gadfly" guided aerially-launched land-attack cruise missiles. Developed in the 1980's. Flies at about 22' above water, or 300-3,000' above ground, using a radio altimeter. Used in Chechnya and Ukraine.
Cost #USD | Warhead Size | Warhead Type | Missile Length, Speed | Engine | Range, Accuracy | Launch Platform | |
S300 | 1 million | up to 143 kg | 19,000-36,000 metal frag,s | ~25' | up to 250 nm | vehicle-based | |
Kinzhal | 10 million | 480kg | Conventional or nuclear | 25' Mach 10 | solid-fuel rocket | 300nm | Tu-22 Mig-31 |
Kaliber | 1 million | 500kg | Conventional or nuclear | ~25' Mach 3 | solid-fuel rocket or turbojet | up to 1300nm | Air, ship, or sub launched |
Iskander | 3 million | 480-700kg | Cluster, thermobaric, EMP, frag, bunker busting, nuclear | 25' Mach 7 | single-stage solid propellant | 300nm 3' - 100' | vehicle |
Kh-101 | 13 million | 400mg | conventional or nuclear | 24' Mach 0.7 | turbofan jet | 3500nm 20-33' | bomber aircraft |
Kh-22 | 1 million | 1,000 kg | RDX or thermo - nuclear | 38' Mach 4.6 | liquid - fueled rocket | 320 nm 300-900' | Tu-22 Tu-95 |
Kh-59 | 500,000 | 320 kg | Cluster, Shape-Charge Frag | 18' Mach 0.8 | 2-stage rocket | 60-160nm | Sukhoi and Mig jets |
Info from Jane's Air-Launched Missiles
Prospects for limb salvage after tourniquet placement has become a crucial matter for thousands of soldiers and their surgeons in the Ukraine war. Near-peer fighting conditions, and lack of air superiority, can create extended evacuation times for casualties. Drone threats to moving vehicles have become so pervasive that, in many areas, the last few miles up to the zero line area only traversable on foot. Beyond this zone, mud, bombing damage, UXOs, and the impossibility of road maintenance make vehicle evacuation slow and bumpy. Patients must often wait for nightfall to evacuate, and dawn-dusk day length at the height of summer on the Eastern Front is 17 hours. Today, almost two years into the war, high attrition rates amongst experienced frontline medics means loss of TCCC tourniquet conversion knowledge along the frontline.
For medics and doctors in forward casualty collection and stabilization points, who are receiving tourniqueted patients after prolonged evacuations from a near-peer conflict area, assessing patient candidacy for tourniquet conversion (i.e. removal and replacement with a simple pressure dressing) or movement of tourniquet to a more distal location is a critical outcome-changing skill. Just as important as assessing limb salvageability is 1) readiness to manage acute complications such as acidosis and dysrhythmias, and 2) ensuring that timely transfer to higher-level care is available for potential mediu-term complications, such as compartment syndrome and acute renal failure.
Current TCCC guidance assumes that limb salvage becomes highly unlikely 6 hours or more after tourniquet placement. However, this guidance is unavoidably based on the extremely limited data pool available to date. Limb salvage after tourniquet placement is a young and weak science, which stands to benefit greatly from case reporting and retrospective studies originating from the Ukrainian conflict. If we look only at the small pool of my personal experience as a paramedic in Ukraine, several case examples of physician-directed conversions of tourniquets in place for over 6 hours have been performed, or given post-conversion management, by either myself or my immediate colleagues. Clearly, amputating every limb that has been touniqueted for more than 6 hours would result in unnecessary negative life impacts for patients.
Current tourniquet science is based on animal studies done in controlled environments, and a very small number of human case reports. Tourniquets are widely used in routine surgeries, but tourniquet use in traumatic wartime injuries is a completely different animal. The reality of warfare adds in a number of important and unforeseen variables, which defy efforts to cleanly categorize patients as <6 hours vs >6 hours:
1) initial tourniquet placement is likely to occur under extreme conditions. Often, the soldier placing the tourniquet has minimal medical training, may be physically and/or mentally exhausted (many Ukrainian soldiers have been deployed for nearly 2 years with little or no leave), he or she may be receiving and returning fire, and may be working in conditions of darkness, loud noise, and confusion. The soldier placing the tourniquet may have reduced fine motor control due to cold, exhaustion, or adrenaline, or may be injured themselves. Weather and fighting conditions may have led to heat exhaustion, dehydration, nutritional deficits, soaked clothing, icy gear, numb fingers, or cold injuries of feet and hands, and rapid assessment and tourniquet placement and/or other bleeding control measures may have to be performed over/through multiple layers of clothing and body armor. Tourniquet availability on the frontlines is limited and likely to consist of a mish-mash of tourniquet brands and styles. These factors often conspire to create "partial-tourniqueted" patients. Tourniquets may be tightened enough to slow, but not fully stop, bleeding and limb perfusion. Venous and capillary return may be cut off, without halting arterial inflow.
2) Due to frontline conditions, time of original placement of tourniquets is frequently estimated, or missing altogether.
3) Environmental conditions and threats during evacuation may necessitate rapid movement and rough handling of the patient, which may lead to tourniquet loosening or temporary dislodgement. Poorly made or re-used tourniquets may stretch over time or fail, lead to placement of multiple tourniquets, and intermittent periods of reperfusion or partial reperfusion.
4) Intentional attempts at tourniquet conversion may be made in the field. Due to fighting conditions, these field attempts may or may not be accurately recorded in the documentation that reaches field hospitals. Patients evacuation routes shift frequently, and patients may pass through multiple patient care teams, comprised of a shifting cast of medical providers.
5) The tourniqueted limb may be subjected to a variety of physiological and environmental conditions, including varying levels of external cooling, varying states of patient blood loss and shock, and varying levels of resuscitative care received.
Due to these variables, Ukrainian doctors cannot rely on hard-and-fast rules such as the 6-hour tourniquet rule. Many tourniquets were placed with good intent, but were never necessary in the first place. Doctors are often forced to decide, based on clinical observations and professional experience, whether tourniquet removal is in the patient's best interest. Does the probability of limb salvage outweigh potential systemic risks to patients? Objective numerical values from blood testing can inform these decisions, if lab services are available. But more often, the critical time for this decision occurs at minimally-equipped forward field treatment points, and thus it must be made based on time of injury, exposure to weather, limb skin color and temperature, injury patterns, and overall patient presentation.
Here is an interesting case report from Kragh et al, published in Orthopedic Trauma in 2007, which represents the realities of tourniquet placement in conflicts, as well as variability in limb salvage times. The patient, an American helicopter pilot in Afghanistan, was shot in the hand and received RPG shrapnel to one leg. Hemorrhage from the hand was stopped 1 hour after injury by a combination of one purpose-built and one improvised tourniquet. Bleeding recurred 6 hours after injury, and was stopped by tightening the tourniquet. The pilot lay in a snowdrift, with temperatures at -15C, for a half-day after injury. After that, he was insulated by blankets made from cut-out aircraft insulation. Evacuation was delayed due to an ongoing firefight, mountainous terrain, and inclement weather. The patient arrived at a forward surgical facility after 16 hours of continuous tourniquet placement. He had severe soft tissue loss, irreparable radial artery damage, and compartment syndrome. He underwent surgical debridement and irrigation, radial artery ligation, and 3 dorsal + 2 ventral hand fasciotomies, and the operating surgeon deemed hand preservation was questionable. Repeated surgical debridement and irrigation took place over the next month, first at Landstuhl, Germany, then at Walter Reed, before primary wound closure was accomplished. Several more surgeries and physical therapy followed, to correct pain and stiffness. By three years after injury, the patient had recovered sufficiently to use the hand for activities of daily living, and to return to piloting Chinook helicopters.
From The Spectator, 23 Aug 2023: 'Ukraine's Real Killing Fields: An Investigation into the War's First Aid Crisis'
In this article, Spectator reporters interview medics from the Hospitallers and the Ukrainian military. Challenges such as military bureaucratic hurdles for replacing medical equipment, corruption, and medical training and staffing shortcomings,
The Spectator is a politically conservative UK magazine. It is the oldest political affairs magazine in print, and its former editors include Boris Johnson and several former UK cabinet members. Until recently the Spectator, along with the Telegraph, was owned by the Barclay Brothers. Back in 2014, the Telegraph Group was criticized for taking Russian funds in exchange for publishing links and supplements of Russian propaganda on Telegraph Group venues. This included reports downplaying Russian involvement in shooting down Flight MH17. These links were later removed. Since the start of the full-scale invasion, the Spectator and the Telegraph have leaned pro-Ukrainian, and have provided a wealth of in-depth reporting on Ukrainian and Russian affairs.
The Telegraph Ukraine reporting and daily hour-long Ukraine podcast
From The Spectator, 23 Aug 2023: 'Ukraine's Real Killing Fields: An Investigation into the War's First Aid Crisis'
Here is a video posted to the english-language Telegram Channel Live:Ukraine on 9 Feb 2023, allegedly showing a hospital in Pokrovsk, Ukraine, at the moment of a bomb impact.
A fascinating feature of the Ukraine war is the amount of real-time information (and propaganda) available to civilians. Daily updates are put out on Telegram, Facebook, and other platforms by the Ukrainian Ministry of Defense, Russian Ministry of Defense, and an array of milbloggers. Civilians post videos of rockets and missiles impacting, or being shot down, which provide the opposing side with battle damage assessments and information of air defense locations. Various 3rd-party open-source intelligence groups collate data and publish up-to-date maps of reported Russian and Ukrainian positions. A network of Ukrainian observers and defense agencies provide instant reporting on Aerial threats via a variety of Telegram channels. This includes radar-detected movements and takeoffs of missile-launching platforms such as Tupolev bombers and MIG jets, launches, locations, and vectors of incoming missiles (including hypersonic ballistic Kinzhals and Iskanders, Kaliber cruise missiles, repurposed S-300 surface-to-air missiles, and Shahed drones. Here's a typical series of missile updates from this week, courtesy of the Telegram channel "Radar".
13:57 Attention! There is activity of enemy tactical aviation in the eastern and south-eastern directions! Threat of aerial weapons launch! In case of air raid alarm announcement in your area, seek shelter. - 39,000 views
14:02 Air alarm for Dnipropetrovsk Oblast! - 38,000 views
14:02 Air alarm for Zaporizhya Oblast! - 37,800 views
14:06 X-59 threat for areas where the Alarm is - 38,900 views
14:18 X-59 headed towards Dnipro - 38.600 views
14:19 Dnipro: take shelter! - 39,100 views
14:19 Zaporizhya: take shelter! - 39,600 views
14:19 X-59 Rocket approaching Dnipro Region - 39.800 views
14:21 Dnipro: Explosions - 41,000 views
14:24 The rocket has been destroyed! (by air defense) -41,000 views
The pelvis has major blood vessels running throug it; fracture or penetrating injury can easily lead to a fatal amount of massive hemorrhage. Pelvic fractures with hemodynamic instability have a 40% mortality. 26% US mil deaths in Afghanistan and Iraq had a pelvic fracture.
Pelvic fractures are generally caused by severe blunt force or blast trauma. Signs and symptoms include:
Pelvic pain and/or crepitus
Deformed or unstable pelvis, unequal leg lengths, or outward rotation of legs (open-book fracture)
Bruising at bony prominences of pelvic ring, anal/vaginal/urethral bruising or bleeding
Neurological deficits in lower extremities
Major lower limb amputation or near amputation
Unconsciousness
Shock
Pelvic binders help return the pelvis to its natural position and lessen bleeding and further damage. There are several purpose-made varieties; an improvised binder may also be made using a sheet or similar object. Pelvic binders should be placed low, at the level of the greater trochanters ("bottom of the patients' pocket openings"). Higher placement can actually leverage open lower-pelvic fractures, increasing damage. One assessment at a major UK trauma center found that 41% of pelvic binders were placed too high. Outward rotation of legs may be observed in displacement pelvic fractures; in these cases legs should also be bound together, in order to prevent further displacement.
An Assessment of Pelvic Binder Placement at a Major UK Trauma Center
1996 CAPT Frank Butler formalizes concepts and experiences from lessons learned in prior conflicts into first TCCC guidelines, and publishes them as an article. These guidelines were presented to DoD leadership, but were not immediately implemented as a universal standard. However, they were adopted by the Naval Special Warfare Command, 75th Ranger Regiment, the Army Special Missions Unit, and Air Force pararescue community.
In 2013 CoTCCC was moved under the Joint Trauma System's jurisdication (JTS). JTS was put together in order to improve military care of trauma patients. It has 6 components:
1) DOD Trauma Registry Management
2) Defense Committee on Trauma
3) Performance Improvement
4) Combatant Command Trauma System Management
5) Joint Trauma Education and Training
6) Defense Medical Readiness Institute
JTS develops and maintains Clinical Practice Guidelines, recommending combat casualty care training requirements, evaluating new medical equipment, facilitating medical performance improvements, facilitating collection and sharing of combat casualty data, maintaining the DOD Trauma Registry, and improving the organization and delivery of trauma care.
Some level of TCCC is required for all US service members. The levels are listed below; ASM is the most basic, and CPP is the most advanced.
ASM All Service Members
CLS Combat Lifesaver
CMC Combat Medic/Corpsman
CPP Combat Provider Paramedic
The latest version of TCCC was released in 2020 and can be found here.
So far, an estimated 25,000-50,000 amputations having already occurred on the Ukrainian side of the war. Patients with tourniquets may not reach definitive care for 24 hours or more after tourniquet placement. Tourniquet times of less than 2 hours have a negligeable impact on limb salvage rates; tourniquet times over 4 hours are associated with reduced limb salvage rates. Amputation of a tourniqueted limb is very likely after 24 hours. Therefore, assessing whether stable patients who arrive at our near-frontline medical facility are candidates for a tourniquet conversion is a priority. "Tourniquet conversion" refers to the process of replacing a tourniquet with a simple pressure dressing.
While civilian prehospital medical personnel are generally taught to never remove a tourniquet once placed, in the US military tourniquet conversion is a basic-level medical intervention. The TCCC guideline, taught to all US military members, is "every effort should be made to convert tourniquets in less than 2 hours if bleeding can be controlled by other means". Temporary tourniquet placement of up to 3 hours, with no resulting tissue damage, is also a common technique used by surgeons.
The process for converting a tourniquet is:
1) pack the wound and apply pressure for 3 minutes
2) apply pressure dressing
3) slowly release tourniquet over 1 minute, watching for bleeding. If bleeding resumes, re-tighten the tourniquet. Re-attempt conversion in 2 hours, as long as it hasn't been more than 6 hours since original application.
4) If conversion is successful, note release time and leave loosened tourniquet on the limb, just above the wound, in case tourniquet re-application is needed later.
Tourniquet conversion is contra-indicated in patients who are in shock, have an amputation below the tourniquet, or who cannot be monitored closely for bleeding. Tourniquets that have been on for more than 6 hours should not be converted. Intermittent reperfusion (Loosening a non-covertable tourniquet temporarily at intervals in an attempt to preserve the limb), is a common surgical technique. However, in field situations without ability to replace lost blood, this is dangerous and ineffective, and not recommended by TCCC.
Ukrainian medic Henri talks with the Prolonged Field Care Collective about conditions in Ukraine: most common injury patterns, weather and exposure, access difficulties, Russian drone attacks on medics, trench foot, dressing complex wounds, penetrating pelvic trauma, prevalence of pneumo-hemothorax over tension pneumothorax, body armor selection factors, and more.
Symptoms of blood loss:
500 mL - well tolerated, may produce slight tachycardia, equivalent to a typical blood donation volume.
1000 mL - tachycardia over 100
1500 mL - changes in mental status, weak radial pulse, persistant tachycardia, tachypnea
2000 mL - confusion, lethargy, weak radial, tachycardia over 120, tachypnea over 35, might be fatal if not managed properly
2500 mL - unconsciousness, no palpable radial pulse, tachycardia over 140, tachypnea over 35, fatal without intervention
The US Combat Wound Medication Pack contains 400mg moxifloxacin, along with 15mg meloxicam and 500mg acetominophen. The Ukrainian medication pack contains a similar assemblage of pills.