WILL THERMOBARIC WEAPONS OVERWHELM THE MILITARY HEALTH SYSTEM? - US Army War College War Room

Thermobaric weapons in high-intensity conflict dramatically change the quantity and severity of blast injuries

In April of 2017, in Afghanistan’s Nangarhar province, the US used a Massive Ordinance Air Blast (MOAB) bomb against a subterranean network of fortified tunnels and bunkers. Accurate casualty totals were impossible to calculate, because any living thing close to the blast area was vaporized; however, casualty estimates range from 36 to 85 killed. Russia has been modernizing thermobaric munitions over the past two decades, it now possesses a bomb four times more powerful than the one the US used in Afghanistan. Recently, Russia used thermobaric weapons against ground forces in Ukraine. During the Battle of Zelenopillya, a single thermobaric strike nearly destroyed two Ukrainian mechanized battalions in a matter of minutes. In Syria, a Russian-made air-to-surface thermobaric bomb struck a market in Douma, killing almost 100 people. Meanwhile, China produces a wide range of thermobaric munitions, from small weapons launched as Rocket Propelled Grenades (RPG) to artillery rockets and aircraft delivered bombs.

From drones to cyber, advancing technologies have the potential to change the character of future warfare. They challenge the US military’s standing practices and measures of readiness. Thermobaric weapons are similar game-changers, particularly because they may undo the US military’s approach to providing medical support forward–an approach cemented under assumptions of a permissive medical evacuation environment and a manageable number of casualties at any given time.

During Operations ENDURING FREEDOM and IRAQI FREEDOM, medical teams demonstrated unprecedented success in treating casualties suffering traumatic blast injuries as a result of conventional munitions. However, as thermobaric weapons become more common on the modern battlefield, we cannot rely on the conditions that enabled effective responses by the military health system in Iraq and Afghanistan. In those conflicts, four key factors improved patient outcomes from blast injuries: (1) freedom of movement to get casualties rapidly to medical treatment; (2) forward surgical services to bring treatment closer to high-risk areas; (3) technical innovation in treatment of severe trauma (such as reducing blood loss immediately following a traumatic amputation); and (4) revised treatment protocols. Survival rates above 90 percent have now become the standard of measure and expectation for the military health system.

In contrast, thermobaric weapons in high-intensity conflict dramatically change the quantity and severity of blast injuries, and do so in an environment in which maneuver is much more difficult, and treatment is much farther away. This creates treatment requirements far beyond what the MHS is organized and equipped to handle. The MHS must change the way it performs its mission to conduct mass casualty operations effectively and maintain high survival rates in an environment where thermobaric munitions are employed.

Consider a Brigade Combat Team from the 101st Airborne Division conducting a forced entry operation into an Anti-Access/Area Denial (A2/AD) environment. Approximately 1100 personnel would be dispersed across an area only a few kilometers wide. Company-sized elements on offensive maneuver each cover 300-500 meters of the forward edge of the battle area. Then the enemy detonates a thermobaric munition over a company’s position.

With a blast yield equivalent to 44 tons of TNT, the bomb creates a destruction radius approximately 300 meters wide, and a blast area approaching 2000 meters. Troops within the immediate blast radius are subjected to temperatures double that of conventional munitions, leading to severe burns of any exposed tissue. Close to the blast, over-pressurization of air in the blast wave causes severe injuries to the respiratory system, ears, and sinuses, as well as blunt trauma. Finally, material displaced by the blast inflicts shrapnel-like injuries on soldiers even further away. The explosion results in hundreds of severely injured casualties.

The few available medical personnel face treating hundreds of individuals suffering severe burns, inhalation injuries, blunt and penetrating force trauma, and major limb amputations. Medical evacuation is not an option; these injuries require immediate on-site treatment or the Soldiers would likely die within hours.

Compared to conventional explosives utilized in improvised explosive devices and vehicle-borne varieties used against US forces, thermobaric rounds pose a greater potential to cause higher numbers of casualties with increased severity of injuries. Thermobaric munitions utilize a three-step process for effect: (1) a conventional explosive or so-called scatter charge detonates in the center of a container filled with fuel, (2) the compression of the fuel creates heat and enhances its reactivity, and (3) once the vaporized fuel is disbursed into the air, it uses atmospheric oxygen to accelerate oxidation, producing an exothermic reaction. When temperatures reach the fuel’s auto-ignition threshold, progressive ignition and explosion results. The ignited fuel vapor produces enhanced fireball temperatures, blast waves of longer duration, higher over-pressurization effects, and greater decompression effects compared to conventional munitions. Adding fine particulate metals—aluminum and magnesium powder often the metals of choice—enable the increased fireball temperatures.

The fuel vapor easily seeps into vehicle compartments, bunkers, buildings, tunnels, and other enclosed spaces before ignition. Medical experts specialized in treating blast and burn injuries find barriers such as sandbags and body armor completely ineffective against thermobaric munitions. Blast waves in enclosed spaces pose a higher risk to humans because waves reflecting off the walls travel at higher velocity than initial waves with multiple waves converging on the victim. Adding the increased blast wave pressure produces traumatic injuries of greater severity. The enhanced blast effects will cause more injuries by the simultaneous harm to multiple body systems. Personnel not in the vicinity of the fireball are still at risk of suffering blast related concussive injuries.

Since Operation ENDURING FREEDOM, the MHS undertook several initiatives to respond to the emergence of improvised explosive devices, with the changes dramatically decreasing death rates due to hemorrhage and immediate complications of blast injuries. Surgical services located near the battlefield, coupled with immediate casualty evacuation, significantly decreased the time from point of injury to initial surgical intervention. Expeditious movement from the field to US-based or Europe-based hospitals optimized patients’ survivability.

One of the most significant factors in Iraq and Afghanistan was the ability of the US and its allies to establish large-scale medical footprints in the area of operations. Small surgical units/teams moved at liberty, and large medical treatment facilities (hereafter, “field hospitals”) were placed forward. Rotary and fixed wing assets positioned at airfields adjacent to most field hospitals were crucial for casualty evacuation missions. In the littoral maritime space, the Navy’s Hospital Ship platform and Amphibious Assault Ship variants operated freely just offshore providing additional surgical services and medical holding capacity.

Blast waves in enclosed spaces pose a higher risk to humans because waves reflecting off the walls travel at higher velocity than initial waves, with multiple waves converging on the victim.

Location of services is vital because studies and anecdotal evidence in the treatment of both civilian and combat trauma have overwhelmingly proven when casualties attain immediate hemorrhage control, receive damage control surgical intervention, and hemodynamic stabilization within the so-called Golden Hour, 60 minutes from the time of injury, have lower mortality rates. One of the greatest benefits of shortened lines of communication from battlefield to hospital is the ability to meet the Golden Hour directive.

In Iraq and Afghanistan, the MHS proved its ability to deal with the most devastating injuries and execute Joint Medical Operations with tremendous success. However, the US cannot rely on future conflicts to be as permissive of such operations. Mass volumes of wounded were not the result of conventional weapons typically used in major wars. The predominant source of serious injuries improvised explosive devices used by irregular forces. Less protected, dismounted troops suffered more debilitating injuries due to pelvic involvement. In large scale conflicts the increased presence of dismounted troops will result in proportionately larger volumes of casualties caused by conventional weapons in addition to those caused by thermobaric munitions.

Although the MHS did very well treating injuries in theater, the conflicts’ asymmetries did not stress the MHS’s maximum capacity. Its success may lead to a false sense of security about its capability to provide the same standard of care in future conflicts. The threat of thermobaric munitions in a contested conventional environment will expose limitations of the current ability to effectively conduct mass casualty operations and attain survival rates similar to those in Iraq and Afghanistan. By interfering with freedom of movement and disrupting lines of communication, less permissive environments restrict location and delivery of clinical treatment. The implications should deeply concern leaders.

Medical personnel moving with tactical units will work without the assured ability to evacuate casualties to higher care facilities. Thus, the requirements to care for non-ambulatory patients will render the unit combat ineffective. Clinics and hospitals will have difficulty keeping up with the transition from maneuver to movement. Restricted air and ground movement will bring about casualty accumulation–exhausting supplies, exceeding holding capacity, and preventing movement. Without replenishment of consumable supplies, sterile instrument sets, and blood products, higher-level care in theater is impossible.

To offset the current limitations of the MHS in dealing with mass casualties from thermobaric munitions, I offer the following recommendations.

First, we must revise training and improve skills within units to manage complications in treating blast casualties. Front-line medical personnel require additional training to handle injuries expected from thermobaric blasts. Because distributive maneuver isolates units and can potentially delay time for casualty evacuation and increase the distance to higher-level facility, augmenting skill-sets and equipment for front-line care providers will be necessary to effectively treat all casualties, especially those caused by thermobaric munitions. For example, intubation (cutting open the trachea and placing a tube to allow breathing) fell out of favor as a treatment for excessive constriction and inability to breathe, but is a proper treatment for inhalation burn injuries and damage to lung structure caused by the effects of having all the air instantaneously expelled. Medical personnel also require greater proficiency in blood transfusion at the point of injury. Additionally, medical evacuation aircrews may require medical training and small inventories of medical supplies to provide basic life support en route.

Second, units need equipment that supports effective treatment on-site, and preserves a unit’s ability to maneuver with casualties. Returning to the intubation example, units should be equipped with commercially-available medical equipment that promotes positive placement of the tube (such as handheld portable devices with cameras and small digital screens), and small, rugged, and simple to use transport ventilators. We also need to continue to invest in technologies that increase the forward availability of plasma and blood, such as the freeze-dried plasma adopted by special operations units. Modifications to military equipment will also improve the effectiveness of medical response on-site, such as using barcoded dog tags to ensure patient-blood compatibility.

Third, we must improve the mobility and survivability of combat medical facilities, and continue to increase the capability and capacity of all medical facilities – from combat hospitals to the highest-level medical centers. The contested battlefield prevents consolidation of combat hospitals, so more scalable teams are needed across the services. This will increase requirements for personnel with certain medical specialties such as general surgeons and surgeons trained in trauma, vascular surgery, and orthopedics. More cardio-pulmonary and respiratory technicians would be needed to manage ventilators and assist in pulmonary treatment. In connection with this focus on improving the mobility and survivability of medical facilities, the US must also recapitalize its air and sea-lift capability, and develop means to offset modern weaponry’s encroachment on the security envelope required to safeguard theater medical operations.

The National Defense Strategy urges the services to prioritize preparedness for war and modernize key capabilities. The lethality of the contemporary warfare demands that we prepare the military health system for its most important function – battlefield medicine. This requires accounting for the types of weapons and capabilities we should expect to face on the future battlefield, then modernizing both what we use and how we work. Thermobaric weapons are today’s realities, and we must prepare for them being employed against us. Without system-wide improvements, the use of thermobaric weapons in a contested environment will expose current shortcomings in the form of increased mortality. Medical teams will need increased capacity, capability, mobility, and survivability at all echelons of care. The US military should prepare its health system under the assumption that the enemy will not afford it the same permissive environment as it has enjoyed in recent conflicts.

Eddie Lopez is a captain in the U.S. Navy and a graduate of the U.S. Army War College resident class of 2018. The views expressed in this article are those of the author and do not necessarily reflect those of the U.S. Army War College, U.S. Army, or Department of Defense.

Photo: An al-Qaida torture compound and prison is destroyed after being hit with six guided bomb unit-38 Joint Direct Attack Munitions from a B-1B Lancer in March 2018 in Zenbaraniyah, Iraq.

Photo Credit: U.S.Air Force photo by Master Sgt. Andy Dunaway