Medical care in submarine accidents.

Submarine emergencies represent one of the most extreme and logistically challenging scenarios in disaster and military medicine, where isolated, high-pressure environments create a perfect storm of medical, psychological, and operational challenges. This perspective examines the unique challenges of providing medical care in submarine accidents, drawing on historical cases such as the Russian Kursk (2000), the Canadian Chicoutimi (2004), the USS San Francisco (2005), and the Argentine Navy’s San Juan (2017) or the Indonesian KRI Nanggala (2021) which illustrate operational constraints and rescue feasibility issues inherent to these types of incidents. The onboard survival phase is marked by rapidly deteriorating conditions, especially on non-nuclear submarines, including hypoxia, hypercapnia, hypo- or hyperthermia, toxic fumes, possible ionizing radiation and psychological stress, as life support systems fail and emergency resources, such as oxygen candles and carbon dioxide scrubbers are finite. Distress signaling is severely limited by the lack of reliable underwater communication, forcing crews to rely on surface beacons without confirmation of receipt, thereby inducing additional mental stress, prolonging isolation and self-sustainment efforts. Rescue operations, for instance coordinated through networks like International Submarine Escape and Rescue Liaison Office (ISMERLO), originally founded by NATO but now a worldwide collaboration, face significant logistical hurdles, including delays in localization, limited Deep Submarine Rescue Vehicle (DSRV) availability, and the complexities of mass-casualty triage, particularly when decompression illness (DCI) complicates trauma management. The dual threat of trauma and DCI necessitates a modified triage approach, where traditional trauma classifications must be integrated with decompression risk assessments to prioritize treatment effectively. Ethical dilemmas further arise in conflict zones, where resource scarcity, security risks, and adherence to humanitarian law introduce profound moral distress for decision-makers and rescue personnel.