Why is the war in Ukraine so deadly?

Voiceover: “The scale of the war in Ukraine is staggering. For context, while the British army is just 73,000 strong, according to US officials, Ukraine's armed forces have already suffered more than 70,000 dead and 120,000 injured. Although Russian losses are thought to be much higher, coping with the volume of casualties is a key issue for Ukrainian medics like Brandon and Iryna of the Hospitallers Medical Battalion.”

Brandon Mitchell: “2022 in Bakhmut. The first day on our position we had over 180 severe casualties. This is what casualty evacuation is like when you want to advance without air support.”

Iryna Knyzhnyk: “I'll never forget that column of ambulances, it was really horrible. 244 people in one day. The doctors, amazing, very really amazing, they are heroes.”

Voiceover: “So, what problems do Ukrainian medics face on the front line? How are they solving them? And what lessons should Western militaries learn from the war in Ukraine? The war in Ukraine is far deadlier than the other conflicts fought by Western powers in the 21st century. Unlike the asymmetric insurgencies which the US and Britain fought in Iraq and Afghanistan, the war in Ukraine is a conventional war with a near-peer adversary.

Improvised explosive devices or IEDs were the main threat in Afghanistan. They caused significant casualties and could injure multiple people at once, but they were largely one off. The conflict in Ukraine sees sustained use of purpose-built munitions. At points Russia has fired over 60,000 shells per day and as a result an estimated 70% of Ukrainian casualties come as a result of artillery and rocket barrages. An identical rate to that seen during the First World War. And that changes the lethality of wounds received in battle. With IEDs, other than the person who triggers the device, they tend to cause less severe injuries and to affect fewer people. While concentrated artillery shelling often results in multiple casualties, each with multiple severe injuries.”

Iryna Knyzhnyk: “Damaged legs, damaged arms, head injuries, lot of head injuries. This can be quite difficult but usually it's artillery. But unfortunately I think bullet wounds, for me, it's more dangerous. Because especially 5.45 calibre is very light and unfortunately they are making mess out of inner organs. Unfortunately I had two casualties which we didn't manage to too save because of that.”

Voiceover: “Not only are the volumes of casualties higher, the percentage of casualties who lose their lives is higher as well. According to The Economist, US forces in Afghanistan had a wounded-to-killed ratio of around 10:1, while in Ukraine this is estimated to be as low as 3:1. To find out why we need to take a look at this diagram. It shows how American casualties could expect to be treated during the Global War on Terror. Progressing from immediate care and stabilisation to a theatre hospital, and then overseas for definitive care. Most Coalition personnel were treated within the so-called golden hour, the first 60 minutes after an injury in which the chances of survival are much higher. But in Ukraine, treating a casualty within the first 60 minutes is almost impossible.”

Iryna Knyzhnyk: “It's a very, very, very rare case. Because of severe shelling only armoured vehicles can come closer to the front line and to the casualty. Sometimes even for armoured vehicles it's impossible to come and evacuate that person. Sometimes it could take 10 hours.”

Voiceover: “In Kherson where Ukrainian Marines have managed to capture a small lodgement on the West Bank of the Dnipro River the situation is even more difficult.”

Brandon Mitchell: “It is impossible to cross the river during the daytime. Into November this year one of my colleagues came under attack by FPV drone with a thermal camera. Now the FPV, Russian FPVs can attack us at night. This is big problem because we only can work at night on the beach. It requires you to be in one spot for 2 minutes, 3 minutes, 5 minutes. This is big problem, you talk about Golden hour. Nobody in Donbass or anywhere is getting anywhere in a half hour, hour, sometimes 2 hours.”

Voiceover: “The challenge of moving casualties from the front line means that Ukrainians are having to change their approach. Training is now focused on prolonged field care, on measures that can be taken by Army Medics on the front line.”

Iryna Knyzhnyk: “But now we began to teach our medics, combat medics to do blood transfusion. It's very important for us because you know the majority of the preventable death is because of loss of blood. So now we began to teach how to do, it's not so complicated just we need just some special equipment for that quite light to keep people longer alive.”

Voiceover: “These battlefield changes pose clear problems for Western militaries. Current US Doctrine asks forward surgical teams to operate on two to four patients and hold 3 to eight patients for 16 to 72 hours without resupply. But Ukrainian teams are estimated to be performing 10 operations and holding 15 critically ill patients for 48 hours without resupply. Expanding a forward team's capabilities would allow them to treat more patients, but it also makes them less mobile and more difficult to relocate. That puts them under threat of attack themselves. In Ukraine, medics and medical sites are a priority target for Russia. According to the Ukrainian Solidarity Project some 200 Ukrainian paramedics have been killed in the last 2 years and over 2,000 health centres, hospitals and ambulances have come under attack.”

Iryna Knyzhnyk: “There was a stabilisation point it was a local hospital in Novovorontsovka and it was just on the bank of the river and from other side of the river were Russians and they were shelling constantly with cluster bombs and surgeons have to do that operation under the shelling.”

Brandon Mitchell:: “These are medical locations. In my 5 months in Kherson the actual hospital has been targeted twice. It's common, it's normal, it's normal."

Voiceover: "In the past medical facilities went out of their way to identify themselves as such, believing it would shield them from attack. Now, in the light of Russian disregard for the Geneva Convention's protecting medical facilities, Western militaries will have to consider how to protect their personnel even hundreds of miles from the front line. While shelling is the main threat in Ukraine, land mines also pose an ever-present danger particularly on evacuation routes.”

Brandon Mitchell: “I personally myself hit two anti-personnel mines in Soledar. The dust got in my eyes, I didn't keep discipline, I didn't keep vehicle distance going into the open. And the truth was when I hit the mines, I felt a heat a very quick heat come over me and everything was yellow. And I've suffered some long-term consequences of that.”

Voiceover: “The battlespace in Ukraine is constantly changing, with both sides adapting to new technologies and tactics. Ukraine is mid-transition from Soviet style care to NATO standards, having had no professional combat medics before 2017. Training times have now been reduced in order to fill the gaps. Another problem is supplies. While volunteers like Irena usually have what they need, Ukrainian Army Medics are beset by bureaucracy.”

Iryna Knyzhnyk: “They prefer to have donations not officially receive the, the medical stuff. Because if the stuff is donated so they have no need to make paperwork. But if they officially receive they have to do it. Even some vehicles. If vehicles was burned out they have just huge, huge amount of work to prove it was hit it was not sold, but was eliminated, so big problem.”

Voiceover: “The over whelming majority of medical supplies for combat medics are still purchased by volunteers. This leads to high levels of variance between units and the levels of care that can be provided. As a foreigner in his unit, Brandon was encouraged by his commander to raise money via YouTube. “

Brandon Mitchell: “I had no social media, I found social media very toxic. But when I seen what it could buy. It could buy generators, it could buy helmets, it could buy cars. If you could build a social media everybody around you would eat better. Many people in Ukraine do this. It plugs all the holes that we, that the government, the state cannot fill.”

Voiceover: “However even if supplies are procured their quality can leave much to be desired. According to Rubryka "Ukraine has no quality standards for haemostatic tourniquets meaning there's no way to block out the bad ones".

Brandon Mitchell: “In the first of the war 30 to 50% of supplies that we were given from other countries in, in volume, in mass had to be thrown in the bin. Many tourniquets do not work or the windless, the turnstile breaks. Quite often they can lose their strength and a bleed that is secured can become a slow bleed. We have so many problems like this, now we have less aid but it's, it's more effective aid it's from those who care and they will also accept feedback. Every day we're improving. We have to, we have to.”

Voiceover: “While Ukraine must adapt in order to stay in the fight against an enemy with much greater means, the west has a choice over which lessons to learn from the conflict. With decades spent fighting asymmetric wars, the conflict in Ukraine is proof that wars with near-peer adversaries have not gone away. Medical care is just one of many areas where the west must adapt to the changing face of warfare. Following Ukraine's example would be a strong start.”