Métodos

care for them. In some situations, civilians can be directed to current and existing local health care facilities. In other cases, especially in extremely poor countries, large numbers of injured civilians may quickly overwhelm U.S. military medical capabilities and impede their ability to support combatants. A clear plan for civilian casualty care must be in place before hostilities begin.

Health care providers anticipating battlefi eld trauma should be prepared to manage pediatric and geriatric trauma, tropical diseases, nutritional diseases, and poorly managed chronic medical conditions such as diabetes.

Medical Preparation for

Urban Combat

Wide dispersal of personnel in small units will decrease direct access to casualties by combat medics. Medics will be spread thin and may not be able to reach a wounded soldier only a few meters away during intense fi ghting. They

FIGURE 26-3 Troops mounted on vehicles while fighting in

urban areas are vulnerable to not only penetrating and blast injuries but also blunt trauma from vehicular accidents. (U.S. Department of Defense photograph.)

FIGURE 26-4 Buildings and other structures are subject

to collapse when targeted by explosive munitions. Locating and extracting casualties trapped in these structures during a battle is extremely difficult and dangerous.

(U.S. Department of Defense photograph.)

FIGURE 26-5 The close quarters of urban combat places

significant psychological stress on combatants. (U.S. Department of Defense photograph.)

also may be quickly overwhelmed by multiple casualties. Units fi ghting in cities must be very well trained in self-aid and “buddy aid”9 _{using the principles of Tactical Combat} Casualty Care (TCCC).

A robust, individual fi rst-aid kit should include a func- tional and easily applied fi eld tourniquet, a fi eld dressing, a hemostatic agent, and the medications recommended by the Committee on Tactical Combat Casualty Care (COTCCC). Units receiving more advanced medical training, such as Special Operations Forces (SOF), can augment individual fi rst-aid kits in accordance with their higher level of training.

Units fi ghting in cities should supplement their organic medical capabilities at all levels. For example, because moving patients over broken, irregular terrain is diffi cult and hazardous to the casualty, an identifi cation-and-litter team should be designated for each infantry squad. Team members should receive additional medical training with emphasis on TCCC, and each team should be issued a robust squad medical kit, including lightweight litters. Support personnel at company and battalion level can be trained in TCCC and serve as additional litter teams.9 _Mounted troops should have an advanced medical kit in every vehicle in case the primary medical vehicle is disabled or destroyed. Individual combat medics should be placed at strong points, at key positions, and with isolated units. During combat in and around Grozny, the Russians augmented each maneuver company with a physician’s assistant and each battalion with a physician and an ambulance company. Surgeons, anesthetists, and additional nurses manned the regimental medical post.10 _{Aid stations and forward surgical} teams (FSTs) should be located as far forward as possible, in locations that provide adequate cover, security, and vehicle access, such as an underground parking garage or basement.3

Medical support personnel present easy, “soft” targets for enemy forces fi ghting an asymmetric confl ict. If medical personnel are to be located well forward, they must be able to provide appropriate security, and they must possess the same battlefi eld awareness and survival skills as the combatant forces.

Evacuating casualties from the urban battlefi eld will be diffi cult and time-consuming. Casualties may have to be carried by hand to a secure consolidation point. As dis- cussed earlier, it may take hours to move a litter patient a few hundred yards over broken, exposed terrain covered by enemy fi re. Unarmored vehicles and ambulances will likely be targeted while evacuating casualties. Even armored vehicles are vulnerable. The M113 Armored Personnel Carrier was called a “death trap” for evacuation of casualties during the 1982 confl ict in Beirut.5 _{These vehicles were} attacked from the upper fl oors of buildings with rocket- propelled grenades (RPGs) that penetrated the thinner armor on the top of the vehicle. Heavy armor such as tanks were used successfully to evacuate casualties during the Battle of Beirut5 _{and by U.S. Marines fi ghting the Battle for}

Hue during the Tet Offensive in Vietnam. The fi ghting in Grozny11 _{and Mogadishu}12 _{proved the need for an armored} ambulance resistant to small arms and RPG fi re that can maneuver over rubble-strewn streets. The Army’s new Stryker combat vehicle ambulance may fi ll this need.

Helicopter evacuation is more dangerous in urban confl ict than during conventional operations (Figure 26-6). The density of urban structures and the proximity of hostile combatants allow few landing zones. Even when a physically adequate landing zone is available, it is likely to be covered by enemy fi re from rooftops and upper fl oors. Helicopters have been downed by small arms fi re during numerous urban battles. RPGs, Stingers, and machine gun fi re have been effective in disabling moving aircraft in both Afghanistan and Iraq. During the Russian fi ghting in Grozny, wounded casualties were normally evacuated to the regimental medical post by armored ambulance, and those with more serious injuries were taken by ground to a secure landing strip outside the city, where they were loaded onto fi xed-wing aircraft.13

Infectious disease is a major threat during urban con- fl icts. Many areas of the developing world where future confl icts are likely have poor public health infrastructure, contaminated water supplies, poor sanitation, and high levels of endemic disease (Figure 26-7). Military confl ict will overwhelm the meager health and sanitation infrastructures of the large, poverty-stricken cities that compose much of the third world. Humanitarian crises generated by armed confl ict in these settings can be massive and should be planned for accordingly. Belligerents fi ghting an asymmetric war will exploit these crises to further their own tactical and strategic aims.

Soldiers interacting with civilians and enemy prisoners will be exposed to endemic diseases such as tuberculosis, malaria, and leishmaniasis. Sexually transmitted diseases such as gonorrhea, syphilis, hepatitis, and HIV will also

FIGURE 26-6 Helicopters provide rapid means of infiltration

into the urban battlefield but are vulnerable to small arms and RPG fire.

CHAPTER 26 Medical Support of Urban Operations

589

pose a serious risk to soldiers if they mix socially with locals. Barrier and personal protective measures should be provided as a force health protection measure.8

Disease vectors such as rats, lice, ticks, and mosquitoes as well as feral animals and unburied bodies will present additional public health hazards.

Potable water will be scarce. Troops engaged in urban and mountainous operations can potentially consume up to 5 or 6 quarts per day (about 20 to 24 8-ounce glasses) depending on the soldier’s level of physical activity and the weather conditions. As the weather warms, daily consump- tion can be expected to increase substantially. Less active troops will need to drink about 5 to 7 quarts (20-35 glasses) per day, and more active troops, 7 to 9 quarts (28-36 glasses) per day. Supplying front-line troops with enough water during urban combat will be diffi cult. Logistic units may not be able to deliver enough water near intense fi ghting,

as discussed earlier. Water resupply may have to be carried by hand or by armored vehicle, severely limiting quantity and consuming valuable manpower. Thirsty troops may be tempted to drink from local sources that may be heavily contaminated by infectious diseases, such as hepatitis, intestinal parasites, or industrial contamination. In one Russian Brigade in Chechnya, 15% of the unit was sick with hepatitis at one time.14