MILITARY MEDICINE, 186, S1:839, 2021
Medical Challenges in Underground Warfare
MAJ Alex Sorkin, MC, IDF
*
; MAJ Roy Nadler, MC, IDF
*
; CPT Adir Sommer, MC, IDF
*
;
CPT Avishai M. Tsur, MC, IDF
*
; LTC Jacob Chen, MC, IDF
*
; BRIG GEN Tarif Bader, MC, IDF
*
;
LTC Avi Benov, MC, IDF
*,†
ABSTRACT
Introduction:
Throughout history, underground systems have served military purposes in both offensive and defensive tactical set-
tings. With the advance of underground mining, combat tactics, and weapon systems, providing medical support in the
subterranean battleeld 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 casu-
alty care are discussed below. As in all combat casualty care, the focus should be on safety, bleeding control, and rapid
evacuation.
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.
INTRODUCTION
The underground warfare doctrine evolved mainly due to
asymmetrical military conicts. The underground warfare
provides unique opportunities for the disadvantaged rivals to
reduce, balance, or even negate the opponent’s ground, air,
and maritime supremacy.
“From a mere tool of war, underground warfare has evolved
into a global security threat of concern to all states,” Daphné
Richemond-Barak 2017.
Since ancient times, soldiers have used underground com-
plexes against besieged cities and ground forces in war
times. Armies applied tunnels for both offensive and defen-
sive strategies, including storage, supply, transport, and
*
Israel Defense Forces, Medical Corps, Surgeon General’s Headquarters,
Headquarters of the Surgeon General, Ramat Gan, Israel
†
The Azrieli Faculty of Medicine, Bar-Ilan University, Sefad, Israel
Presented at the 2019 Military Health System Research Symposium,
Kissimmee, FL; MHSRS-19-01941.
doi:10.1093/milmed/usaa447
© The Association of Military Surgeons of the United States 2021.
All rights reserved. For permissions, please e-mail: journals.
permissions@oup.com.
ambushing. Utilizing the underground environment came as a
response to the establishment of fortied cities, which posed
a great challenge for breaking in, thus providing a cunning
method for inltrating sieged cities.
The underground complexes are used as a strategic weapon
since biblical times. King David used a water sluice to
conquer Jerusalem from the Jebusites. Hundreds of years
later, during the Bar-Kokhba revolt, Jewish rebels built shel-
ters in caves and tunnels to hide from the Roman empire
conquerors.
1
During the same time, the Romans employed
underground warfare in the Roman-Persian Wars, and so did
ancient China in the Warring States Period.
2,3
Thousands of years later, in the early 20th century, sieg-
ing fortied cities and digging tunnels under the enemy lines
to damage its guarding posts appeared outdated and irrele-
vant to the modern battleeld. However, this notion did not
last long. World War I was mainly trench warfare follow-
ing a short phase of penetration. Both sides were bound to
develop creative ideas to overcome stagnation, and along-
side the rst tanks and chemical weapons, the underground
warfare redeveloped. The mission was to utilize civilian
mining knowledge, experience, and technology gathered
after years of quarrying underground transportation routes
MILITARY MEDICINE, Vol. 186, January/February Supplement 2021 839
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