“It's not the sight of blood that scares you but the possibility of making a mistake.” Confessions of frontline medics

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“You get used to soldiers' wounds, but the sight of wounded children throws you off.” Oleksiy Yudkevich, Ukrainian combat medic

I am a combat medic. When the ATO started, I joined the army and took a tactical medicine course there. During the full-scale invasion I was involved in evacuating civilians together with a group of volunteers. It all started when a former colleague of mine needed to evacuate his family from Chernihiv. We figured out a relatively safe route and managed to evacuate them. Word spread quickly, and people started calling me on the phone asking for help. Later we received a request to evacuate a maternity hospital where infants had been abandoned – they needed special care, and there was no way to provide it, the city was under massive shelling. We were given a critical care vehicle, and after a successful evacuation we were offered to keep the vehicle. Requests for help did not stop and considering that our group included quite a few people connected with military medicine, we decided to get serious about rescuing the wounded on the front lines.

We have several teams of doctors and paramedics, most of whom are willing to travel with me in their spare time. There is a team from the Zaporizhzhia Fifth Hospital, they swap shifts to free up 10 to 14 day stretches. In addition to doctors, there are volunteers on the teams. For example, we now have paramedics from Sweden working with us. There were times when we went to hot spots as part of special units. For the past four months we have been helping at the stabilization station in Bakhmut.

We have a specialized platform at our disposal: an ambulance equipped as an operating room on wheels, and a critical care vehicle, which allows us to perform so-called tactical evacuation. Depending on the location, the evacuation chains may differ. Sometimes we pick up a wounded person, give him first aid and take him to a stabilization station where the medics work on him. Sometimes we ourselves act as medics at a stabilization station.

If a wounded person has a thoracic injury rather than a simple shrapnel wound and needs special care, such as drainage or blood transfusion, we take him beyond Bakhmut - to Kramatorsk or Druzhkivka, performing all the required manipulations on the way. For example, when blood sampling is required on the road, we signal the driver to drive slower. After all, this is not an ordinary IV with plastic tubes, but a procedure that utilizes an iron needle, and if you jerk it around the needle can damage blood vessels, but if the tactical situation allows it and there is no shelling, I tend to provide the maximum amount of assistance on the spot, because the chances of the patient being saved decrease exponentially over time.

Every trip is special, and every time something new happens. Two months ago in Bakhmut we were the only ones who could provide full medical care, because the local 93rd brigade only had gurneys in their ambulances, and a single ultrasound machine for the entire hospital, including two operating rooms.

We have a team of doctors who work according to the Damage Control Surgery protocol, a field surgery tactics that had learned in the United States. This format is also called SOST - Special Operations Surgical Teams. When we travel with such a team, I assist in surgeries - my qualifications do not allow me to perform surgical intervention: I can perform tracheal intubation or blood transfusion, but I cannot perform a thoracotomy, for example.

In 9 out of 10 cases we deal with the consequences of mine blast trauma. Patients fall into three categories. The first are those who are going to die anyway, because they have injuries that are incompatible with life. More often than not, you start treating such wounded people and already in the process you realize that the patient cannot be saved. For example, you see a massive bleeding from a limb, and then you take off the helmet and see another shrapnel wound under it, and there's nothing you can do about it. The second ones are the ones who survive anyway, even if we don't pick them up. Survivor statistics are mostly based on them, although they would have survived even without us. The third ones are those whose lives depend solely on the actions of medics, and this group is the most difficult, the statistics are very bad, and unfortunately there’s no good way of working with them now.

One of the frequent causes of death is external bleeding, that is, bleeding from the extremities, which is very easy to stop. It's the eighth year of the war, and in most cases we have people who don't know how to use a tourniquet <a device for temporarily stopping bleeding - The Insider>. It's pretty common to deal with a minor wound where a tourniquet wasn’t needed, but was installed, tightened and left for six hours anyway. And as a result, a soldier who might have returned to duty in three weeks ends up with an amputated limb. Or vice versa, a tourniquet wasn't installed, and we had a corpse that had already bled out. If the person who provides first aid turns out not to be competent enough, it may end either in death or in tragedy.

Another cause, which in 90% of cases leads to a fatal outcome, is massive internal bleeding. It can be prevented by following the Damage Control Surgery protocol, which few people here know. It seems to be a simple procedure: open and put a clamp on, in most cases tape over and rush to a hospital, but we keep taking him from one stabilization station to another until he suffers hemorrhagic shock. In most cases, the chief medical officer, to whom a wounded person is delivered, thinks that crystalloids (inexpensive saline solutions, for example, physiological solution) are a good thing and in case of massive blood loss it is necessary to inject the person with Ringer solution, while dry plasma is black magic. But in fact, dry plasma can be very effective in the field. In the event of massive blood loss, it can replenish a large volume of blood. We had some dry plasma stored in our critical care vehicles, but two months ago one of them was hit by a rocket, and the other one blew up when its oxygen tank detonated.

One day we received a wounded man who, according to all the documents, was lightly wounded. He had a non-penetrating abdominal wound - a piece of shrapnel had chopped off a piece of skin, and his condition was classified as acoustic barotrauma - damage to the inner ear. But as we were loading him into the vehicle and strapping him down, we found he was in hemorrhagic shock due to a hip fracture. A hip fracture is very insidious – it's difficult to detect on initial examination, and it's fraught with massive internal blood loss: up to two liters of blood can get inside the muscle, which was what had caused hemorrhagic shock. After noticing this, we began reevaluating the patient, we identified the fracture, performed bone traction, and only because we had dry plasma with us, we managed to keep him alive until we reached the hospital, and he survived. If the crew of the 93rd brigade, which was on duty that day, had arrived instead of us, it would have been a guaranteed fatal outcome.

Our work is mostly difficult and unpredictable, and you get used to it, but there is always something you can't get used to. On our last trip, the city fell under heavy fire, and the Russian military hit an apartment building. Our guys pulled a three-year-old girl out of the building; she had injuries that were incompatible with life. She died on our table. And while you get used to military injuries quickly, injuries to children throw you off. Children are the hardest part of this story, because for unknown reasons they still stay in the cities, and when you see shell-shocked children playing in the street, it's so... well, it's kind of hard.

Just like my first combat experience in 2014, when I first saw a wounded man and went into a stupor. As it turned out, this is a fairly common reaction. It wasn't until my partner slapped me in the face that I got going. But it becomes harder later, when you find yourself in a calmer situation and able to reflect on everything. Then it becomes frightening: you realize that there were a thousand possible ways for the situation to develop, and it could have been much worse.

“Medics do crazy things, drugs are in short supply, which leads to huge preventable losses.” N., a Russian intensivist

I have not been to the front line myself, and Russian doctors who work at the front lines are strictly forbidden to speak with journalists, so they are unlikely to talk to you. But I talked to military medics who regularly go to the front lines, and they spoke in detail about their work and showed me pictures. They are very critical of the medical equipment for doctors and paramedics - everything is obsolete, everything is in short supply, and there’s practically no training being provided to the people who work there, so preventable losses are very high: about 30% of those who die from wounds on the Russian side die from non-fatal wounds (for comparison, on the Ukrainian side this figure is 5%). That is, sometimes it is enough to apply a normal tourniquet to prevent a person from dying, but either there are no normal tourniquets, or there are no tourniquets at all in the kit, or there are not enough first aid kits, or everything is there, but the medics are untrained – and in the end there’s a huge number of preventable casualties.

The main thing that is missing from the kit is good blood-stopping material. There are special substances that are placed in wounds, hemostatic agents that stop the bleeding, good tourniquets and pressure dressings, but they are either Russian-made or Chinese, and work very poorly, while the Ukrainians have high-quality stuff, so Russian military medics are very happy when they get a chance to take first-aid kits from wounded or killed Ukrainian soldiers and grab everything they were supplied with. The best stuff our medics have is the stuff they managed to steal from the Ukrainians.

The Ukrainians have well organized paramedics who come and pick up the wounded, apply tourniquets, stop the bleeding and take them to a place where they can get help. It's true that they have stopped putting doctors in the evacuation vehicles, only trained non-medical personnel - because their evacuation vehicles are targets for our armed forces. They are very fond of finishing them off because usually there is a large number of soldiers in every such vehicle. It is a war crime to kill wounded evacuees, and of course no one would ever say it on the record. But a doctor I know proudly told me those vehicles were being “quickly punished and destroyed.” They don't even hide it, they are proud of it – if they see an evacuation vehicle with Ukrainian wounded, they try to destroy them.

Military doctors have several levels: medical unit, medical platoon, hospital. First, they do some critical stuff on the battlefield under fire, then, when possible, they take the wounded to a more or less safe place they can be helped, then they take them to the medical unit, where only doctors work, and then, when a large number of wounded is accumulated, they evacuate them to the nearest hospital, for example, in Rostov or Belgorod. Those with heavier wounds are taken to Moscow and St. Petersburg. A lot of doctors have been mobilized. Mobilized doctors try their best to get hospital assignments. Most of them don’t want to work on the battlefield.

In general, the level of training of doctors on the ground is quite poor, but the authorities cannot send good, experienced military doctors because they have huge workloads at their places of work, so the most qualified ones stay in Moscow and St. Petersburg. The authorities keep sending poorly trained doctors, who can’t do a thing, hence the massive loss of life and limb, which could have been prevented if medical care was organized properly. An acquaintance of mine showed a video of Ukrainian doctors at work: they are so professional that it’s clear they had been getting instructions from the United States or Israel, they had been trained to follow their protocols. They have protocols they’ve been trained to follow automatically: measures to be taken to prevent a heavily wounded soldier from dying quickly, to stop the bleeding and avoid life-threatening situations that can cause a soldier to die within next few minutes or hours, then deliver the wounded soldier in that condition to a hospital with highly qualified medical staff. All it takes is simply the execution of an algorithm and the availability of good consumables. You can see that the Ukrainian side has everything and that they had been trained because I doubt they knew how to do it in the first place. Very good training.

The medics I talked to were armed. They don't fight, they carry firearms just in case. They can use their firearms until there’s a need to tend to a wounded soldier. A peacetime acquaintance of mine is a pediatric intensive care physician who worked in a regular children's hospital in Moscow. Some patriotic feelings kicked in, he decided to go and play war, he actually went as a volunteer. It’s not even a question of money, he just likes it very much. He is about 45 years old, he is brainwashed, he tells you how “khokhly” and “pindosy” <derogatory terms for Ukrainians and Americans> should be killed and then he shows you videos of how well everything is organized on the Ukrainian side, and how bad everything is on our side. And if you ask him why we should bring the Russian world to Ukraine and not vice versa, he has a ready answer at once: “They are doing well, because they have been preparing for the war for eight years, unlike us. We didn't know we would be going to war.” He is quite professional in medical terms, but absolutely brainwashed on the topic of war. On the whole, those with whom I spoke were pessimistic, but not in the sense that we will lose, but in the sense that the war will be very long. How they psychologically cope with what is going on, I do not know exactly, but my acquaintance looks as if he’s a regular drinker.”

“After being surrounded, we had to acquire shooting skills.” Kateryna Galushka, a Ukrainian paramedic

I'm an Oriental historian, but back in 2019 I decided I wanted to do something for the victory and found myself in paramedicine. I took a course in the “Hospitallers” volunteer medical battalion and became part of it. After that, I started my trips to Donbass as a military paramedic.

We serve in rotations on the first line, we call it “ground zero.” It is equidistant from all trench positions on the battlefield. You are on duty is 24-7 when on a rotation. If you're asleep, you wake up, go and pick the wounded up. The rotation itself can last anywhere from two weeks to infinity, depending on how long you're willing to work. Unlike those who serve under contract, we make our own schedule.

According to the MARCH and TC3 protocols, we should not provide first aid while on the battlefield because it endangers the lives of both paramedics and the wounded. Accordingly, the maximum that can be done in the trenches is to put tourniquets on a person's limbs and quickly load them into a vehicle. And while the vehicle is on the move to the second stage of the evacuation, we provide all the necessary aid: stop massive bleeding, ensure normal breathing, air circulation, deal with any complex injuries that require surgical intervention, stabilize the wounded person, that is, administer antibiotics, painkillers, and infusions.

We usually try to do everything very quickly, before shelling starts. We can work under heavy shelling, but we need to stay away from the fire, especially from small-caliber guns such as machine guns and assault rifles. It’s always for the paramedic team commander to decide whether to pick up a wounded soldier under heavy fire. There were times we wouldn’t be allowed to go or I myself would decide not to go, understanding I could not put the lives of other team members at risk. I can risk my own life, but not the lives of others.

The war showed that even medics need to know how to handle weapons. Initially our battalion commanders were not happy with this, but after Mariupol, where medics had been encircled, many of us learned basic shooting skills - because you never know what might happen and where these skills might be needed. I’ve also taken special courses and try to practice at a shooting range once a month.

When you see someone wounded, it's not the sight of blood or injuries that scares you, it's the thought that you might not be able to cope. Even after three years, I still have fears I might not do enough, but fortunately, no one has died in my hands. While treating my first wounded soldier, I was very afraid I might fail to tighten the tourniquet or bandage the wound the right way. The most important thing in such situations is to remember that a person's life is in your hands, and it depends on you whether they will be able to return home. I always try to stay calm and stick to protocol, convincing myself I’m doing the best I can.

Before March 5 I simply did my job as I was supposed to, and it had no effect on my psychological state, but afterwards, when the man I loved died, it became very hard for me seeing a man wounded, let alone killed. On top of that, I’ve been constantly experiencing a lot of shocks that I don't have time to reflect on.

When I see a dead person, I always think that the man I loved was probably lying like that too, or that someone close to me, who is also at war now, might be wounded as well. Sometimes it's psychologically hard to bear it. As for the wounded, it's hard for me to work with them, too: I worry about them, I want them to survive, because I know what it's like to lose someone, and so I get nervous a lot. But I always try to remember why I got into this in the first place.

Since the start of the full-scale invasion, I have been working in an area of defensive, rather than offensive actions, which is why shrapnel wounds from mortars and artillery are what I have to deal with in most cases. I did not encounter many bullet wounds, only four, but they were the most difficult to treat. Lately there have been a lot of wounded, especially those who stepped on anti-personnel “petal” mines. They are dangerous because they are invisible and blend well into the environment. “Petal” mines are often scattered across the grass or within urban environment, and when a soldier steps on such a mine, it either rips off his foot or severely injures him.

Paradoxically, I feel safer at work than I do at home. When I’m on a rotation there is always a man on duty to warn me if there’s any danger, and when I am on leave I may not hear the sound of an air raid and no one will be standing next to me with an assault rifle.

“The guys don't understand why they didn't die, and more importantly, why they were there at all.” K., a Russian military surgeon

I have worked as a military doctor all my life, and what's happening now doesn't shock or scare me in any way - it's not the first time in my life that I've seen wounded people. It's my job, just like any other doctor's, just a little bit different. The only difference is that in peacetime there are fewer wounded and now there are more, but I cannot name specific figures, nor can I speak about my work with servicemen brought in from Ukraine - I signed the relevant documents.

I try not to think about the war, because if I start naming the recent events in this way, I will have to make an assessment of it, take a stance, but I can't take a stance. My duty as a surgeon is first of all to save people, to save as many as I can, not to ponder on who’s right, who’s wrong and who’s to blame for what’s happening. Besides, you know very well what position I’m required to adhere to. This is not about medicine.

When you encounter the first wounded in your life, you are scared, but not of blood (I would hardly have gone to medical school had I been scared of blood); you are scared of not being able to make the right decision, you don't want someone to die because of your fault. Psychologically it is hard, but we’ve been taught, or ourselves learned, to cope with it.

What we are dealing with now are textbook cases of everything that can be found in military surgery: all kinds of soft tissue injuries, fractures, amputations, shrapnel wounds of different character and degree. It all depends on who was brought to us, whether the person blew up on a mine or came under fire.

A lot of mistakes have been made by those specialists who worked before us and apparently were dispatched to the front without proper training - after being treated by them patients often lose their limbs, and that's not the worst thing that can happen. I see these mess-ups very often, and I realize that if the wounded person had been treated by a more competent specialist, he would have probably kept his limb. I know who is being sent to the front now, there’s a large medical community, and doctors share information with each other. When you hear that a specialist is being sent to the front who has just graduated from university or hasn’t even graduated yet, you understand what will happen to his future patients. Often even we are not able to rescue a patient, despite the fact that we are not on the front line and can provide the appropriate care. By and large our hospital, in spite of the level of the specialists' training, turned out not to be ready for the influx of wounded and for working in such conditions - quite often there is simply no necessary equipment to conduct research.

A lot of wounded are being brought in, and often they are young guys who have not yet had time to live, but are already disabled, unprepared for, and internally broken by, what has happened. I've seen a lot of those empty eyes lately - guys don't understand why they're alive, why they didn't die, and most importantly, why they were there at all.

“Sometimes we work without lights, the generator is only for the operating room and ICU.” P., a Ukrainian military surgeon

Before the war, I was serving at a mobile hospital in the Joint Forces Operation area in Donbass for two years and I could not leave the compound for more than fifteen minutes, because at any moment a wounded person could be brought in. The conditions were almost the same as now, the only difference being that there were a thousand times fewer wounded.

It’s always scary to look at them, although the concept of fear is incompatible with medicine. We worry a lot about patients, especially when there are unusual cases and it's hard to decide what to do right away. But, fortunately, we don't work alone: there's a whole team of specialists in the hospital, some of whom have 20-25 years of experience in military medicine or surgery. Personally, I treat wounds using external fixation devices and amputations, but I can also help surgeons of other specialties if need be. It is important to understand that we provide comprehensive specialized care, but not highly specialized, because the wounded are subsequently taken to big cities for further comprehensive treatment.

70% of the wounds are soft tissue related, and this number is similar to the World War II statistics; some of them are gunshot fractures of bones, small or large. The character of the wounds largely depends on whether it was artillery fire, rocket attack, air raid, landmine or small arms fire that caused them. What matters is the kind of explosive that was used in the mines.

A wounded person may have a huge piece of shrapnel embedded in his body that does not affect vital organs, or he may suffer from small wounds, with some of the vital organs injured. For example, a patient has no major injuries, only a small shrapnel wound in the shoulder with damage to the brachial artery. Such an injury, if not treated in a timely manner, can result in either amputation of the arm or severe blood loss, causing shock and death. There are only ten minutes to apply a tourniquet.

Before a patient goes to the hospital, other medics work on him. It's a lot harder. If we have a calmer situation, the pre-hospital doctors have to get the wounded man out of the battlefield and quickly administer first aid. It sometimes happens that a wounded serviceman cannot be extracted for several days due to prolonged shelling, when everyone is under enemy fire, and medics need to make sure that he makes it to us and doesn't die. That's why our fatality rate is minimal: it all depends on timely action on the front lines.

A few days ago, we had to work during a blackout, with a huge number of patients coming in. For such cases, our hospital has a generator, which serves the operation room and intensive care unit. But only 10-15% of the wounded need surgery, the rest are sent to the wound dressing rooms or the antishock rooms. When there is virtually no lighting, it is difficult to work in those rooms. There are also big problems at the triage stage: it is necessary to separate the heavily wounded from the lightly wounded, without missing any wounds that are not clearly visible - the size of an entry wound can be as small as one millimeter.

There are a lot of wounded, but some of them you get to remember for a long time - not because of the severity of their wounds, but because of their specific stories. I had one patient from Mykolaiv. When he served in the Luhansk region, his daughter was killed. Another one was from Lviv, he worked as a gardener before the war and went to the front without any experience. He had such kind eyes. War snatches people away from peaceful life and forces them to take up arms.

I hear a lot of stories from lightly wounded patients as I dress their wounds or talk to them before surgery. They tell me what the situation on the front line is like, where they are from. Most of the wounded I remember well are amputees. Those are mostly traumatic amputations, when a piece of shrapnel cuts off a foot, an arm, a hand, a forearm or a hip. It’s hard to forget such patients because they are young guys who should have been enjoying their lives, working hard and playing sports. But tragedy comes into their lives when they lose a limb.

Depending on the unit they served in and their age, they cope with it in different ways. Professional servicemen understand that they are alive and that they will be able to play sports and even serve with a prosthetic limb, while recruits and civilians don't believe they can cope; it's very difficult psychologically for those patients. I recently had a wounded man, with a foot attached to the leg by the skin and two tendons. Before the surgery, the foot was cut off because it was easier to move the patient that way. It was already almost a complete traumatic amputation without reconstruction of the arteries and the bone, which occurred due to a massive tissue injury that will never heal.

About 70% of our patients are already miss a limb and understand they will be left without one. At the same time, they feel no pain, because they are under heavy sedation and may be in a state of shock, but not because of the injured limb, but because of massive blood loss. Our goal with such injuries is to preserve the tissue as much as possible so that we can strengthen it in the future for getting a good residual limb to fit into the socket of a prosthesis. There are cases when, even after our help, a limb still has to be amputated because of huge bone or soft tissue defects, artery damage, or a bacterial infection. We do everything to keep the limb alive - we treat and cut off non-viable tissues, but that is no guarantee it will stay that way.

In today's weather conditions, especially when the fighting is going on on a swampy terrain, hypothermia is added to combat injuries. Recently a patient was brought to us who had been in the field for three days without water or food, with gunshot wounds to his shoulder and shin, hypothermia and terrible pain. He had been pushed away from his position and was unable to rejoin his unit. We operated on him, and he miraculously survived, such cases are very rare.