Not war, not terrorism, the impact of hybrid warfare on emergency medicine.

INTRODUCTION: Healthcare facilities and medical providers are not immune to aggression and threat from terrorists, criminals and rogue states. The concept of Hybrid Warfare is often described as a mix of conventional warfare, irregular warfare, terrorism, criminality and different types of other hybrid threats such as cyberattacks and drone technology. Healthcare systems can either be primary or secondary targets of hybrid warfare with potentially devastating consequences. OBJECTIVE: The aim of this paper is to serve as a primer for clinicians, researchers and emergency managers in understanding the basic aspects of hybrid warfare, how healthcare can be affected, and to provide a framework for mitigation and resilience, especially in an emergency medicine setting. Different hybrid threats and their effect on emergency medicine, and healthcare in general, is discussed. DISCUSSION: Hybrid warfare is an increasing, multimodal, threat for all segments of healthcare, particularly prehospital care and emergency medicine. Disrupting the healthcare system in a country using hybrid warfare has the ultimate aim of destabilizing organizations and society as well as directly reducing the effectiveness and capabilities of healthcare as a key strategic resource. In this aspect prehospital care and emergency medicine are main targets of aggression. CONCLUSION: Clinicians and healthcare managers of all levels should have a basic knowledge of the different components of hybrid warfare so as to mitigate effects of an attack. It is suggested that an emergency department do not aim to create totally new solutions for hybrid threats but use an all hazards approach and the available guidelines for handling generic threats. However, there must be a preparedness for the different ways hybrid warfare can play out, how the threats can be combined in synergistic ways and the potential compounding effects on healthcare and society.

Preparing for hybrid warfare and cyberattacks on health services' digital infrastructure: What nurse managers need to know.

AIM: This article aims to outline the key concepts in hybrid warfare and cyberattack to better inform nurse managers in their strategic contribution to the defence of critical digital infrastructure. BACKGROUND: Hybrid warfare often targets a nation's critical digital infrastructure including that of health services. Hybrid warfare against national health services, primarily through cyberattack, is likely to increase in a more destabilized and conflictual international environment. EVALUATION: Key literature, reports and assessments on hybrid warfare, advanced persistent threats and cyberattack referenced to health services were analysed. KEY ISSUE: Health services are a key element of a nation's critical digital infrastructure and as such are a strategic target in hybrid warfare. Cyberattack through exploiting clinicians', such as nurses, online susceptibilities is a key route of attack. Nurse managers, to be effective planners, need to be fully informed about the context and specific nature of cyberattack. CONCLUSION(S): Articles about the relationship between hybrid warfare and cyberattack on health services digital infrastructure are rarely aimed at nurse managers. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers need to be fully informed about the geopolitical nature of cyberattacks if they are to be fully consulted and listened to in response planning in defence of health services' digital infrastructure.

Hybrid warfare and counter-terrorism medicine.

INTRODUCTION: March 9, 2022. An airstrike by Russian forces destroying a maternity hospital in Mariupol, Ukraine. The image of a severely injured pregnant woman covered in blood being stretchered away against the backdrop of destroyed buildings. Mutterings of the use of chemical weapons. This paper is a primer for healthcare personnel and health systems on hybrid warfare and counter-terrorism medicine. DISCUSSION: While recent events and images arising from conflicts around the world represent a cruel hallmark in today's history, attacks against healthcare facilities and innocent civilians are not new and continue to be perpetrated around the world. In war, the Geneva Convention protects civilians and healthcare institutions from harm but when war crimes are being committed and civilians knowingly targeted, parallels from a healthcare perspective can be drawn with terrorism events. Increasingly, civilian institutions and in particular the healthcare sector, are drawn into such conflicts and understanding the health system impact of hybrid warfare and other asymmetrical attack methods is of great importance. CONCLUSION: The field of Counter-Terrorism Medicine (CTM) explores the healthcare impacts of intentional, man-made attacks and much recent research and discussions around this topic are extremely relevant and applicable not just to the ongoing hybrid war in Ukraine, but to today's threat climate all around us.

Russia's Hybrid Warfare in Ukraine Threatens Both Healthcare & Health Protections Provided by International Law.

Hybrid Warfare is on display because of the unjustified Russian invasion of Ukraine. This is characterized by numerous crimes against civilians as seen vividly during the occupation of the town of Bucha where rape, torture, murder, and looting seem to reflect Russian military policy, leadership, and command guidance. Of particular concern is the threat to hospitals and health care as well as vital life support. Numerous hospitals have been damaged and destroyed. Hospitals are not tactical military targets and targeting health care facilities and personnel ignores traditional jus in bello and ignores numerous conventions established to stabilize the global order. The Russian-proclaimed "special operation" in Ukraine has been characterized by barbarian warfare in which the Russian military uses weapons against the civilian population and civilian infrastructure. The aggressors have embarked on a purposeful terror campaign through infrastructure attacks, which are of little military value except to demoralize the nation's people. This is evident with Russian missile and drone attacks on electric, water, and health care in Ukraine. Warfare now and in the future may be increasingly aimed at demoralizing civilian populations and reducing the will of the people and their government to resist. The Ukrainian invasion clearly shows that this use of hybrid warfare should be met with a strong reaction of the international community at the earliest possible stage, especially the supposedly peace-loving neutral countries, or else the future is expanded unlawful and barbaric military conflict.

Attacks on Ukrainian healthcare facilities during the first year of the full-scale Russian invasion of Ukraine.

BACKGROUND: Although the Geneva Conventions and Rome Statute demand protections for healthcare facilities during war, breaches of these protections are frequently reported. The ongoing war in Ukraine is no exception, with several healthcare attacks eliciting widespread condemnation. The Ukrainian Healthcare Center (UHC) has been collecting, verifying and documenting attacks on health infrastructure since the Russia-Ukraine War was launched. The aim of this study was to assess UHC documented healthcare facility attacks during the first year (24 February 2022 to 25 February 2023) of the full-scale Russian invasion of Ukraine. METHODS: The Berkeley Protocol on Digital Open Source Investigations was used to document healthcare attacks. Data collection included temporal factors, location, facility type, attack and weapon type, number of killed and injured healthcare personnel and civilians, and whether facilities were damaged, destroyed or attacked more than once. RESULTS: There were 334 documented attacks on 267 Ukrainian healthcare facilities, with 230 facilities being damaged and 37 destroyed. General hospitals, primary care clinics, emergency departments and children's hospitals were most frequently targeted. The majority of attacks took place during the first three months and in eastern Ukrainian oblasts. Heavy weaponry was employed in almost all attacks. The total number of casualties included 97 fatalities and 114 injuries. CONCLUSIONS: During the first year of the full-scale Russian invasion of Ukraine, there were 334 attacks on 267 Ukrainian healthcare facilities documented by the UHC. Heavy weaponry was commonly used, and the direct impact of attacks was considerable in terms of facility damage and casualty tolls.

From peacetime to war: a path analysis of the factors that predict performance among police and military commanders in collaborative crisis response.

Purpose: This study aimed to examine the applicability of Bandura's social cognitive theory in predicting organizational performance in dynamic and ambiguous hybrid warfare contexts. Specifically, the study investigated the influence of dyad composition, past performance in peacetime, collective self-efficacy, and persistence on wartime performance among high-ranking police and military commanders. Study design/methodology/approach: One hundred and thirty-eight participants, consisting of police and military commanders, took part in a simulation exercise that escalated from peace to war. The participants were assigned to three types of dyads (N = 69); all-police (n = 20), all-military (n = 27), and mixed police-military (n = 22). The study utilized path analysis to examine the direct and indirect effects of the variables on wartime performance. Results: The model developed in this study accounted for 54% of the variance in wartime performance (R2 = 0.54). Path analysis showed direct effects of persistence (ß = -0.33) and peacetime performance (ß = 0.45) on actual performance in wartime. Direct effects also showed how persistence was predicted by dyad composition (ß = -0.24) and peacetime performance (ß = -0.50). Indirect effects indicated how persistence mediated the effects of peacetime performance (ß = 0.17) and dyad composition (ß = 0.08) on actual performance in wartime. Originality/value: This study contributes to the understanding of how social cognitive factors, as described by Bandura's theory, can predict decision outcomes in collaborative crisis response settings involving police and military commanders. The findings have implications for policy-making and provide recommendations for further research in this area.

The new humanitarian crisis in Ukraine: Coping with the public health impact of hybrid warfare, mass migration, and mental health trauma.

One of the largest mass movements of displaced people from their homelands in recent history must be recognized and assisted by the Free World. The unprovoked Russian attacks on Ukraine during February-March 2022 will leave long-lasting devastating effects on millions of innocent victims. Nations worldwide, especially NATO member countries, will need to intervene to ameliorate the situation. This letter describes major public health issues apart from the COVID-19 pandemic that are emerging concerns, such as shortages of healthcare professionals, chronic care treatments and health prevention services, disinformation communication campaigns affecting the healthcare infrastructure, and the generational impact of the conflict on people's mental health. A global response and public health support need immediate action including humanitarian assistance, food security, clean water supplies, adequate shelter, and safe transportation out of the active military zones.

"Emerging Technologies and Medical Countermeasures to Chemical, Biological, Radiological, and Nuclear (CBRN) Agents in East Ukraine".

Since 2014, Ukraine has been beset by an armed conflict with international and internal dimensions. The nature of this conflict is multidimensional, and disaster preparedness and response in this context must be as well. Health experts from Ukraine, the United States of America, United Kingdom, Czech Republic, and Norway convened for an educational event in Dnipro, East Ukraine on November 11-15, 2019. At the event, "Emerging Technologies and Countermeasures to CBRN Agents: Advanced Training Response to Conflict and Security Challenges in East Ukraine," over 1,000 participants participated in panel discussions, didactic lectures, and an advanced training on various dimensions of disaster response. This report provides an overview of the key discussions and outcomes of the event.

Pulmonary artery embolism by a metal fragment after a booby trap explosion in a combat patient injured in the armed conflict in East Ukraine: a case report and review of the literature.

BACKGROUND: Pulmonary artery embolization due to projectile embolus is a rare complication in combat patients. Such embolization is rare for combat patients in the ongoing armed conflict, in East Ukraine since 2014. CASE PRESENTATION: We report a clinical case of a 34-year-old Caucasian combat patient who was injured after an explosion of a booby trap hand grenade. This soldier was diagnosed with severe abdominal and skeletal trauma: damage of the duodenum and transverse colon, internal bleeding due to inferior vena cava damage and fractures of both lower extremities. The patient was treated at a highly specialized surgical center within the "golden hour" time. Whole-body computed tomography scan was performed as a routine screening method for hemodynamically stable patients, at which we identified a projectile embolus due to the explosion of a booby trap hand grenade in the right midlobar pulmonary artery. Our patient had no clinical manifestation of pulmonary artery embolism. At follow-up, our patient was diagnosed with the following complications: multiple necrosis and perforations of the transverse colon leading to a fecal peritonitis; duodenum suture line leakage caused the formation of a duodenal fistula; postoperative wound infection. These complications required multiple secondary operations, and in accordance to the principles of damage-control tactics, the extraction of projectile-embolus was postponed. Open surgery retrieval of the metal fragment was successfully performed on the 80th day after injury. Our patient was discharged from the hospital on day 168th after injury. CONCLUSIONS: Literature analysis shows a significant difference of clinical management for patient with projectile embolism in hybrid war settings as compared to previously described cases of combat and civil gunshot injuries. Damage control tactics and the concept of the "golden hour" are highly effective for those injured in a hybrid war. A whole-body computed tomography scan is an effective screening method for asymptomatic patients with projectile-embolism of the great vessels. The investigation of a greater cohort of combat patients with severe injuries and projectile-embolism should be performed in order to develop a better guideline for these patients and to save more lives.