UkraineWarfightingactivity:

epidemiologicalsnapshotassessment,
FebMarch2015

Medsanbat:PatrickChellewandJohnQuinn
ExecutiveSummary
ThewarinUkrainehasstrainedanalreadystressed,depletedandshockedmilitaryand
civilianhealthcaresystem.ThemultiplekicksandstartsofscatteredandfierceRussian
ledincursionsthroughoutUkrainiansovereignterritoryhasleftamedicalevacuation
vacuum,increasedmortalityofpreventabledeathonthebattlefieldandacivilian
healthcarecrisisstillbeingdescribed.BasedonMedsanbattrainingthroughouttheATO
andthefrontlines,datahasbeencollectedonwarfightingactivitytoprovidean
epidemiologicalprofile,evenifonlyqualitativeinpart,hasbeenperformed.This
concludeswithkeyrecommendationstomitigatearegionalhealthcarecrisisand
disasterreliefwithaplanofpracticalactionformedicalsupportfromNATOaligned

countries.ItshouldbehighlightedthatthedisconnectfromKyivmilitaryandcivilian
supportunitswithunitsservingintheATOandfrontlinesisimprovingbutstillhasmany
gapsandprovestobeamajorbarriertomedicalcommandandcontrolandbasic
operations.Dnipropetrovskremainsthecenterformedicalexcellenceandhas
continuedtoreinventitselfasamajorleaderinclinicalbestpracticesandasabeacon
foralltraumapatientswithwarfightinginjuries.

Thisreportistoserve4keystreams:1)reporttheroughestimatesofnumbersof
casualtiesandwhichhospitalssharethegreatestburden2)provideaclearerpictureof
whatcareisbeingcarerenderedandwhatmoreisrequired3)Medsanbatnetwork
observationofthefirst24hoursofpointofinjurytopointofcare(toserveasanupdate
topreviousreporting)4)toofferacoherentmedicalexpertplantoserveamultipurpose
efforttomitigatepreventabledeathonthebattlefieldandtoprovideastopgapto
increasedmorbidity.ThemedicalunitsintheATOhaveshowngreatresilienceto
adversityintheirreactionsandactionstochallenges.Theproposedmedicalplanfrom
MedsanbatoffersasustainableandorganicapproachtoUkrainianMinistryofDefense
(MoD)medicalcommandcapacityforfutureoperations.Theexpertopinionsexpressed
hereareconcludeduponthroughevidencebasedpractice.Thedescriptionportionof
thisreportprovidesonlyasnapshot.Theurgentrequestsareforamobilehospital,
furthernonlethalmedicalsupportinsoftandhardgoodsandtheconsiderationof
defensiveweaponsystemscapability.Theveryrecentmedicalfacilityandevacuation
vehicleattacksinthechronicescalationofhybridwarfaredeployedbyRussiahave
proposedanewandchangedthreattomedicaloperations.

KeyRecommendations

CombatLifeSaver(CLS)mentorship

CLSMedicalSupplies(pleaseseeANNEXA)

TacticalCombatCasualtyCare(TCCC)mentorshipandtraining

CombatMedicMedicalSupplies(pleaseseeANNEXB)

Expertisesharing,mentorshipanditerationsoftraining

MobileHospitals(2)

Role2/3[1]withlimitedsurgicalcapability(anesthesiaand
damagecontrolsurgeryX2)

Labs,xray,carmxrayforexternalandinternalfixation

CTscanner

Serveasacenterformedicaltraining,CLS/TCCCtraining
andmentorship,disasterpreparednessandmedicalcommand

AccesstofixedwingNATOcountrymedicalevacuationfromtheatretorole4
facility(increasesurgecapacityforMoD,MoHandMoI)

NATOcountryprosthesissupportandrehabilitationmentorship(occupational,
psychologicaletc).

Ventilators(portableandstationary)(16(sixteenunits)tosupply4unitsateach
mobilehospital:fourmobilehospitalsofvaryingcapacityarecurrentlydeployed)

Portablemonitorsforcriticalcaretransport(ECG,pulseox.,temperature,BPand
capnography)

PortableUltrasound:ExtendedFocusedAssessmentwithSonographyinTrauma
(eFAST)(20)

Medicalsupportequipment
:

ArmoredHumveesforCASEVAC(40)

Armoredtrackandnontrackvehicles(MRAPs)(40)

Advancedmedicalcommunicationssuite(land,airandsea)multipleunits

GabionHescobarriers(90,000squaremeters)

Considerationofadditionalnonlethalassistanceshouldinclude:

Counterbatteryradars

Unmannedaerialvehicles(UAVs)

ElectroniccountermeasuresforuseagainstopposingUAVs
ImmediateBackground
Ukraine'scasualtiesaregreaterinnumberandseveritybecauseoftheirrelatively
underdevelopedandseverelyunderresourcedmilitarymedicalsystem.Despitethe
multipleunitsandvolunteerbattalionsnowworkingtogetherandbecomingmore
operationallyeffectiveintheATO,theresourcesarestillinconsistent,attimespolitically
motivatedandinmanycasesnonexistent.Medicaloutcomesandtheevacuationchain
isgreatlyimpactedbythisthussoldiersaredyingfrompreventablebattlefieldrelated
deathasaresult.

Inadditiontotheabovenonlethalitems,theU.S.governmentmayconsideritspolicy
changefromprohibitinglethalassistancetoallowingprovisionofdefensivemilitary
assistance,whichmayincludemultipleformsoflethalassistance.Enhancedmilitary
assistancewouldincreaseKyivscapabilitytodeterfurtherRussianescalationand
attacksonmedicalsupportfacilities.

UkrainianlightantiarmorcapabilitiesareseverelylackingatatimewhentheRussians
havemovedlargenumbersoftanksandarmoredpersonnelcarriersintotheDonbas

(6070percentoftheirexistingstocksoflightantiarmorweaponsdonotworkandare
notbeingdeployed[2].AntiarmormissileswouldgivetheUkrainianarmythecapability
toimposeheaviercostsonadvancingRussianunitsandsupportthedisruptionofsuch
attacksandfurtheradvancements.Itispossiblethatbyraisingtherisksandcostsof
incursionsandattacksandadvancementsbyRussianunitswillhelpdeterfurther
Russianoffensiveoperations[2].

DeployedEnemyWeaponsSystems
Asnote,weaponssystemsdeployedbytheenemythroughouttheATOincludethe
following,butnotlimitedto:(thislistisnotexhaustive)theT64,T72
R
ussiantank,
RPG18s,7s,22s,24sand26s,Totchka(SS21),Buratino(TOS1),120mmmortars,
theBM21Gradsystem,clustermunitions,SmerchSystems,UragonSystems,122mm
Howitzer(D30)artillery,Cy25assaultaircraft(Russiacontrolstheairthroughoutthe
ATOandthislimitsaeromedicalevacuation)andthe7.62caliberAK47,theAK74rifle
andtheVSSsniperrifle.Themechanismsofinjuryfromthesecommonweapon
systemswillnotbediscussedindetail,theirinjurypatternsaredescribedbelowinthe
resultssectioneachmedicaltreatmentfacility(MTF).

TriageandEvacuation
TriageisaverydifficulttopicinthemilitarymedicalsysteminUkraine.Thereare
culturalandsystemslevelissueswithapproachtodisastermedicineandacceptanceof
theconcept,greatestgoodforthegreatestnumber.Therearedocumentedrules,
edictsandlawsfromtheMinistryofHealth(MoH)andtheJusticeDepartmentthat
dictatehowtoperformtriageandthismaycomplicatemattersformanymedical
professionalswhendealingwithwarfightinginjuriesandmasscasualtyincidents
requiringsurgecapacity.

Withthis,thereisacultureandstructuretofocusonprobablesurvivabilityalonein
triage,andmanymedicalprofessionalsinterviewedconcentrateonlyonpatientswho
haveveryhighlikelihoodsforsurvivalthisisinordertoavoidblameorlegal
persecutionofpotentialpoormedicaloutcomesforpatients.Clearly,theincentivesare
notinthefavorofbasictriageanddisastermedicinebestpractices.

MedicalEvacuation
Evacuationhasundergonedramaticshiftfromnonexistentandconvolutedtoa
defacto
volunteerandMoD/MoI,slightlylessconvolutedevacuationchain.Byfar,thegapsthat
remainaretoomanylinksinthischain,theabsenceofarmoredelementsservinginthis
chainandthelackofairsuperioritytoservewhereandwhenneeded(fixedandrotary

basedmedicalevacuation).Medicalevacuationhasantiquatedmedicalcommand,
limitedpatienttrackingcapabilityandaninadequatemedicalstaffbaseorairassets
devotedtothisservice.

Arecentinternalreport(November2014)fromMoDUkraine,basedonincomplete
morbidityandmortalitydatafromtheATO,commentontherealitythatterritorial
(civilian)basedhospitalsserveasmainreceivinghospitalsformilitarycasualties.This
hasbeenaconstantthroughouttheATO.Militaryandcivilianassets,resources,
hospitals,

Methodology
ThisisacombinedqualitativeandquantitativereviewofATOrelateddatafrommultiple
sources.Thesedatahavebeensentfrommedicaldirectorsinfromthesetreatment
facilitieswithnostandardcollectionprotocol.Thesedataareanecdotalinnaturebutto
theauthorsknowledge,noothercollectionorrepositoryexistsapproachingsucha
comprehensivereviewuptodate(March2015).
Limitations
Alldatacollectedarefromdifferentsources,reportsandlevelsofcare.Thesedata
wereNOTuniformlycollectedbutshouldserveatthesinglesnapshotorcrosssectional
anddescriptivestudyofmortalityandmorbidityforwarfightingactivityintheATOand
frontlines.Somedataareverycurrent,uptoMarch1st/2nd,2015otherdataaredated
tomid/lateFebruary2015.OtherdataarelostasmanyMTFsintheciviliansectorhave
fallentoenemyhandswhileotherMTFsmaynotkeeporwereunwillingtodivulgeany
patientdatadespitethescopeofthisreport.Noextensiveincidence,prevalenceor
mortalitycalculationshavebeenprovidedduetothedescriptivenatureofthesedata
andinconsistentgathering.

Results
ThecombatareainUkrainehasbeendividedintofoursectors,
SectorAintheNorthEastregionaboveLugansk,
SectorCcoveringtheareaontheNorthWestflank,
SectorBcoveringmostoftheareainthewest
andSectorMcoveringtheSouthandthecityofMariupol
(pleasesee:
Referencemap
attheendofthisreport).UponeachvisittotheATOone
canseemarkedimprovementoverthetreatmentandevacuationoftheinjuredand
improvedoutcomesofsurvivabilityforinjuredwarfighters.


Onepotentialcauseforthisanecdotalimprovementmaybefromtheincremental
enhancementstotheexistingfourUkrainianmobilemilitaryhospitals(MMH)anda
betterworkingrelationshipwiththeexistingcivilianhospitalsintheATOandfrontlines.
Theseimprovementsincludebetteraccesstorunningandpotablewater,24hourpower
access,basicintensivecareunit(ICU)facilities,monitorsandheat,ventilators,ABGsor
basic/oradvancedlabs(thoughmuchisantiquated)andabetterrotationofsurgeons.

TherearenowfourMMHintheATO,threeofthemworkcloselywithanexistingcivilian
hospital.Thefourth,standsaloneinthesouthwestandhasmovedlocationstwicein
thepast4months.Therealsohasbeenamarkedincreaseofmilitarymedicalpresence
intheATO,theintroductionofaNationalGuardMedicalUnitandcoordinatedvolunteer
assistancethroughthePIROGOVFIRSTVOLUNTEERMOBILEHOSPITALa
coordinatedpartnershipbetweenthecivilianandprivatesectorandofcourseprograms
similartoMedsanbat.Thiscoordinationisstillinitsinfancybutisgrowingandisstill
gettingorganizedtomitigateaduplicationofservices.

Evacuationhasimproved,monthonmonthsinceNovember2015toMarch2015.For
example,2448hourevacuationsaredowntoasingledayinmanycaseswithsome
patientsreachingKharkivorDnipropetrovsk(regionalrole4MTFs)inaslittleas48
hourswithsomesurgicalstabilizationperformedatoneofthecivilianormilitaryfacilities
intheATO.Someofthesecasesreportedarewithpatientsreceivinginitialbuddyaide
atpointofinjurywithlocalmedicalsuppliesorviaIndividualFirstAidKits(IFAKs).
However,itmustbehighlightedthatonly710%ofactivewarfightersintheATOand
frontlineshaveafunctionalandstandardizedIFAK.

UponreceiptandstabilizationataRole12MTF(militaryorcivilianbased),patients
thanareloadedinanyavailabletruckorarmoredpersonnelcarrier(APC)forfurther
transporttoamobilehospitalorreceivingcivilianMTF.Thisisusuallywithoutadevoted
medic(noactivetreatmentrenderedenroute).Therearemultipleanecdotalaccountsof
treatmentwithdieselofasingledriverandattendantwithmanypatientsintheback
goingover120150km/hsomeoftheseresultingincrashesandonereportedfatality
(aboneyardofcrashed,detonatedandlargecaliberriddledambulanceshavebeen
seenthroughouttheATOindicatingthatMVCsarenotuncommon).Severalsoftskin
ambulanceswereambushedanddestroyedallpatientsandancillarymedicalstaffwere
killedduringtheBattleofDebaltseve.

UponarrivaltotheclosestandsafesttransportrouteMTF,patientsreceivetheirfirst
advancedcare(thisisathour24postinjury,insomecases8+hours),stabilizedand
movedbysoftskinMoD/MoHambulancetoamobilehospitalorcivilianhospital.

Thisiscarriedoutwithlittleornoequipmentandwhenoperationallyavailable,evaced
viaMi8helicopterwithlimitedornomedicalequipment.Therearecurrentlyrumored
four(34)devotedrotarywingedaircraftformedicalevacuation.Theofficialnumberisa
statesecret,thatnoonewaswillingtodivulge.Thereareafewscatteredcriticalcare
transport(CCT)ambulancesavailable,usuallysuppliedbyavolunteerorganization,
officialnumberunknownandqualityandlevelofcareprovidedunknown.However
duringthebattleofDebaltsevemanysurgepatientswereloadedinatruckwithlittleor
nocareandmovedtoeithertoKrasnoarmiyskorArtemivskfortheirfirstcontactwitha
higherlevelofcare(36hourstransportdependent).

BreakdownofSectors

SectorA
Hospitalsthatnowhavemilitaryassistance:Novoaidar,SchastyaCityHospital,
Lysychanskcentraldistricthospital,Starobil's'k.Recentdatacollectedandconfirmed.

LuhanskregionSectorA
Takenof3monthstime:600700casualtiesfromvariousunits(Aidar,92nd,80th
brigades,borderguards,etc.).

1.

Ballisticinjuries:200250people
2.

FraginjuryisthemostcommonbyGradandUragansystems(noSmerchorBuratino
yet)
3.

Severeamputationsarethirdmostcommonpresentations
4.

Casualtieswhosteppedonamineorboobytrap(boundingmunitions)
5.

Inexperiencedsoldiersaccidentallyshootingfeetandhands

Evacuation
MedicalRepSectorA:Afterbeinginjured,thesoldierisinstantlydraggedoutofthe
battleandputintoavehicleanddriventoStarobilskwherealltheinjuredintheAsector
go.30minsmaximumforfirststage.Duringthattimetherewereonlytwotimeswhen
therewasnocartotakethecasualtyrightaway.ThedrivingtimetoStarobilskisusually
40mins2hoursinaverage.FromStarobilskpatientsgotoRegionalCentersineither
KharkivorDnipropetrovskandthenKyivandOdessa.Thetransportationtimeis24
hoursforamoderateinjury.Iftheinjuryissevere,thepatientsremaininresuscitation,

andafterbeingstabilized,assoonastheycanbetransportedtheygotoahigherlevel
facilityusuallyin23days.

Allhospitalsintheareaaresupplementedwithasurgeon,anesthesiologistand
therapist/orneuropathologist/orneurosurgeon.Furtherevacuationforsometo59th
militarymobilehospitalinSvatovo.ThecivilhospitalinShchastyawasbombedandis
outofserviceattimes.ThisMMH/Sectoristheonlyonenotfullyvisited.Evacsto
KharkivfromDebaltseve5hrs,fromStarobil's'k4hrs.Airevacuation1hourif
available(roadsareinpoorconditionthroughoutthearea).NoCTcapability.
Neurovascularsurgeryavailableinthemobilehospital/areabutnoburrholesare
allowedtobeperformedwithoutaCTscanpriortotreatment.

SectorB
Hospitalsthatnowhavemilitaryassistance:Kostantynivka,Selydove(patientsfrom
Pisky,Donetskairport),Dimitrovo,Kurakhovocityhospitals.Patientsaretransported
eitherdirectortothe66thMobileHospitallocatedattheRailroadUnionHospitalin
KrasnoarmiyskandKrasnoarmiyskCentralDistricthospital.Transporttimeisaboutone
th
th
hourfromthefrontlinearea(February25
28
,2015).Fromherepatientsareeither
airevacedortransportedbygroundtoMechnikovDnipropetrovskRegionalClinical
HospitalbutoccasionallytoKharkivbyair.Selydove(seereportbelow)tookthebruntof
thepatientscomingoutofPiskiandtheDonetskAirport.


66thMFHTraumaRoomatRailroadHospital
SectorC
Hospitalsthatnowhavemilitaryassistance:Debaltseve(takenoverbyRussia),
Popasna,Sviltodarsk,Myronivske,LuganskeallgoingtoArtemivskCentralDistrict
Hospital.ThishospitalisoneofthelastremaininghospitalthatcanbeconsideraLevel
IIIfacilitygivenithasCTaccessandfullsurgicalabilities).Ithasalwayshadgreatlocal
supportandmaybethebestfacilityintheNorthernregionintheATO.Airevacby
helicopterusuallytoKharkivbutusesDnipropetrovskaswell.Theareahasbeen
shelledandwillbereadilyshellifanotherpushisattemptedoutofDebaltseve.Itisalso
supplementedbytheNationalGuardMedicalUnitandPirogovVolunteerMobile
Hospital.

Furtherevacto
:
1.Kharkiv(militarymedicalclinicalcenteroftheNorthernregion).Kharkivmilitary
hospitalhasreceivedmorethan5000patientsfromATOsinceJune.DuringtheBattle
ofDebaltseve,KharkivMilitaryhospitalpeakedat170patients/dayfromtheATO.Can
managehigherflowsusingcivilianfacilities(e.g.regionalhospitalor1200beds,
emergencycareinstitutefor700bedsetc).

Whenoverwhelmed,KMHprovidessocalled"limitedmedicalcare"i.e.delaypatients
whocanwaitforanother1012hours.

2.65thmobilehospitalinKrasnoarmiyskandthentoMechnikovDnipropetrovsk
RegionalClinicalHospital.AirevacisdonedirectlytoDnepropetrovskAirport,then
transportedbyambulancefora20minuteridetoMechnikov.
.
Durationofevac:
1.

3560minutestoArtemivsk
2.

1hourforstabilization
3.

11.5hoursforairevacforDnipropetrovskandKharkiv
4.

4hourevacuationbyvehicleonbadroadstoDnipropetrovsk(furtherinjuries
reported)
5.

3hourbyvehicleonbadroadsKharkiv

AmbulanceentranceArtemivskCentralDistrictHospital(65thMFH)

SectorM
PostpatientsareevacuatedtoVolnovakhaandMariupolfromthefrontlines.The
hospitalsaresupplementedbyMoDstaffandpatientsareeitherevacuatedbyground

tothe61stortransportedfromVolnovakhatoMariupolwheretheyareeithertransferred
tothe61storsometimesevacedtoDnipropetrovsk.Thosepatientsevacuatedtothe
61stmobilehospitalinKuibysheve(61st)air/groundevactoDnipropetrovskor
sometimestoZaporiz'kafordefinitivecare.CTavailableoutsidehospitalinMariupol.

Hospitals
TopfourhospitalsforpatientvolumeinATO(notlistedbyvolume)
Selydovesupplementedwithmilitarystafffromthe66thMFH
Krasnoarmiyskwith66thMFH
Artemivskwith65thMFH
Mariupolsupplementedwithmilitarystafffromthe61stMFH

SnapshotofSelidoveCentralCityHospitalpatientdata02.03.2015
1.Typesofinjuries,numberofinjured
SincethebeginningofATO,SelidoveCityHospitaltreated515military.
Amongthem:

10GSW

458fragmentinjuries

47bruises.Fractures

Injurylocation:

head48

extremities237

abdominalcavity15

thoraciccavity33

polytrauma110

concussion72
2.Careprovided.Furthercareneeded.Specifics
Medicaltriageof515injuredprovided.Partoftheinjuredhospitalizedandtheother
receivesoutpatientcare:

Surgicaldebridement191

Majorsurgery92

Chesttube14

Osteosynthesisoperations17

Cast50

Treatmentinresuscitationunit40

Vesselshunting5

Craniotomy5

Laparocentesis7

Thefollowingcareisprovided:
Transportimmobilizationofextremities,administrationofantishockmedicine,pain
medicine,antibiotics,applicationoftourniquetsbandagingandresuscitationevents.

SelidovoCCHreceivesinjuredbothfromcivilpopulationandfrommilitary.Sincethe
beginningoftheATO39civilinjuredwereadmitted,whoreceivedfollowingcare:

Outpatient7

Inpatient32

Furtherevacuationdependsoftheseverityoftheinjuryaccordingtothefollowing
points:

1stcategorytotheunit,iftheinjuryisnotsevereandtheconditionofthesoldier
allowsthemtostayonthebattlefield

2ndcategorythosewhoneedqualifiedmedicalcarefrommilitarymedicssent
tomobilehospital

3rdcategoryneedspecializedmedicalcareinDnipropetrovskmilitaryhospital

Injurypattern:

Numberoneinjury:frag
o

Neck
o

Head
o

Lowerextremities,mostlyhips.
o

Manyfractures,spiralandtraumaticburstinnature

Manyinjuriesrequiringexternalandinternalimmobilizationoffracturesnounits
availableatthisMTF

NobasiccastbandagesavailableatthisMTF

DnipropetrovskMilitaryHospital
Totalnumberofcasualties1025
06.2014
49
07.2015
248
08.2014
289
09.2014
109
10.2014
56
11.2014
47
12.2014
26
01.2015
104
02.2015
97

Ballisticinjuries:
Spineandspinalcord=1%
Peripheralnerves=2%
Bigvessels=2.5%
Otolaryngologicalorgans=3%
Organsofsight=4%
Pelvisandorgansofthepelvis=5%
Abdominal=6%
Headandface=8%
Chest=9%
Limbs=65%

DnipropetrovskCivilianHospital

ThisMTFisbyfarthebestRole4equivalentvisitedandworkedwithinthatstrivesfor
improvementdaily.SinceMay9,2014MechnikovaHospitalhasbeentreatingpeople
whowereinjuredincombatintheATOzone.Forthelast10monthsMechnikova
hospitalhadoneabsoluteprioritysavinglivesoftheinjured.Despitethecriticaland
unpredictedcurrentsituationthisMTFhavemanagedtoadaptquickly,retoolandcreate
averyeffectivealgorithmofgivinghighlyqualifiedmedicalcaretoaverylargenumber
ofcasualties.OnFebruary25,themedicaldirectorforATOinjuriespresentedthebelow

datatotheCentralMilitaryHospitalinKyiv,andtheworkofMechnikovahospitalhas
beenacclaimedbytheheadsoftheMinistryofDefense,thePresidentofNAMNUand
Medsanbat.

Categoriesofcasualties:
1.

WarfightersfromtheunitsundertheMoDofUkraine:(regularmilitaryunitsand
battalionsoftheterritorialguard).
2.

Officersandsoldiersfromtheborderguard.
3.

SBUelements.
4.

ElementsfromtheunitsundertheMinistryofInternalAffairsofUkraine(partsof
internaltroops,theNationalGuard,Azov,Aidar,Donbas,Shakhtarsk(Tornado),
Dnipro1volunteerbattalionsandallotherbattalionscertifiedbytheMinistryof
InternalAffairs).
5.

FightersfromtheRightSectorvolunteerbody,aswellasOUN(Organizationof
UkrainianNationalists)andKarpatskaSich.
6.

Civilianpeople,includingonechildaged16.
AsofMarch1st,1193casualties,whospentmorethan9500beddays,havebeen
treated.

Casualtiesforthegivenperiodoftime,May2014Feb2015:

May16patients

June27patients

July107patients

August309patients

September131patients

October101patients

November62patients

December43patients

January174patients

February227patients.

Themostheavilywounded,inmostcasesfromthefrontline,withoutbeingpreviously
givenanyqualifiedhelp(onlyselfaidandbuddyaid),weretakentothehospitalin
JuneJuly2014.Propertriage,antishockmeasures,bloodtransfusiontherapyand
stoppingthebleedinginmostcasesdidnottakeplace.

ThenumberofcasualtiesdecreasedinAugustSeptember2014,butsincethestartof
2015,thisMTFreportsasuddenandconsiderableincreaseofthenumberofcasualties
withheavyblastandballistictrauma.

Asaresultofthedevelopmentofnumerousmobilehospitals,thathavehighlyqualified
specialistsandarewellequipped,allcasualtiescometoourhospitalaftershockbeing
treated,bloodtransfusiontherapydoneandallneededemergencycaregiven
prehospitablyinmobilehospitals.Complexsurgeries,includingvascularsurgery,are
nowreportedtobeperformedinthemobilehospitals,avoidingnumerousamputations.

Problems
:afterlongvascularsurgeriesthisMTFreceivespatientswithhemoglobin
below45g/dL.Thereareinadequatebloodtransfusiontherapy,includingtheuseof
cellsavers.

InjuryPatterns

Polytrauma
Thestructureofinjuriesincludesinorderofvolume:
Limbfracturesfromballistictrauma
Penetratingthoracoabdominalinjuries
Barotraumafromtheblastwave
Ballistictraumaofheadandneck
Spinalinjuries
Burns

Statisticaldatashowthat38,4%ofcasualtieshavegonethroughresuscitationand
anesthesiologydepartments.Thedeathrateis1,1%inhospital.SinceMay9,950
urgentsurgerieshavebeenperformed,including250repositionsoflimbfracturesfrom
ballistictraumawithexternalfixationapparatuses.

Theprofessionalismofneurosurgeonsofthehospitalallowedperformingmorethan60
mostdifficultsurgeriesbecauseofballistictraumaofbrainandspinalcord,peripheral
nerves,magistral/backbonearteryofheadandneck.Strongandeffectivecooperation
amongsurgicaldepartments#1and#2andprofileresuscitationdepartments
(anesthesiologydepartmentofintensivecare#1,polytraumadepartmentofintensive
careandsepsisdepartmentofintensivecare),aswellasactiveinvolvementofthechief
surgeonandchiefthoracicsurgeon,helpedtosavethelivesofthefighterswiththe
mostseverethoracoabdominalinjuries.Accordingtothevitalneedsofthecasualties,
thefollowingamountsofbloodhavebeentransfused:FFP221,8l,RBCs331,1l,
thrombocytes53doses,cryoprecipitate305doses,albumin59,4l.

Alldepartmentsconnectedwithemergencycarearebeingusedfortreatingcasualties:

Departmentwitharesuscitationroomandurgentsurgicalblock

Emergencycareanesthesiologydepartment

Polytraumaintensivecaredepartment

Anesthesiologyandintensivecaredepartment#1

Sepsisintensivecaredepartment

Anesthesiologyandintensivecaredepartment#2

Traumatologydepartment#1

Surgicaldepartment#1

Surgicaldepartment#2

Neurosurgicaldepartment#2

Earmicrosurgerydepartment

Maxfaxsurgery

Vascularsurgerydepartment

Vascularneurosurgerydepartment

Psychosomaticdepartment,wherepsychologistswork

Onemoredepartment,probablythekeyone,withoutwhichitwouldvebeenimpossible
tocomeevenclosetotheresultswehavenowattained,isundoubtedlythevolunteer
teamswhohelptheinjured.

Mainissuesconnectedwiththemedicaltreatmentofpatientsinjuredincombatinthe
ATOzone,are(internalsupplyproblemsnotaccountedfor):
1.

Morethan50casualtieswillneedmodernhightechprosthesis.Notavailablein
Ukraine
2.

TheadaptationofmedicalestablishmentsofMIAsysteminDnipropetrovsk
regionaccordingtothespecificexistingconditions:creatinganopportunityfor
thecasualtiesofsurgical,traumatologyandneurosurgicalprofiles,tostayin
theseestablishments.
3.

Requiredalgorithmoffurthertreatment,rehabilitationandVLKforvolunteerunits,
whohavenotbeencertifiedbytheMoDandMIA:UkrainianVolunteerBody,
OUNbattalion,KarpatskaSichbattalion,etc.
4.

Economicexhaustionofvolunteersupportincaseofasurgeinpatientvolume
overnext2to8months,thehospitalwilllackcriticalmedicalsupplies.

KyivMentalHealth
March2015,660patients,over500beingtreatedasoutpatientsandinpatientsfor
stressrelatedpathologies(PTSDandacrossthespectrum).Thesystemis

overwhelmed,poorlypreparedforthemultiplepresentationsofbattlerelatedstressand
bestpracticesarebeingfollowedwithsubsequentpoormedicaloutcomes(anecdotally).
Arenotmanagingwell,andcouldusehelp.Roughly300bedsinKyiv,500patientswith
mixofinandoutpatient.

Potentiallongrangemedevac,C130.Landingfields.
Dnipropetrovsk(recommendedwithdirectcontactsandcooperationfromthe
directorandstaff)
Kharkiv
Kramatorsk(ATOHQ)
Mariupol(butUkrforcesdonotuseregularlyduetothethreatofManpads)

UkrainianManagementPlan
Insum,thenextphaseofmilitarybattlefieldmedicinetosupporttheATOandprovide
TCCCstandardsofcareistoincludeamobilehospitalsystem.Thissystemwillinclude
2internationalmobilehospitalswithRole2toRole3NATOcapability.TheMobile
hospitalwillactasacenterofmedicalexcellenceandbeaugmentedbytheRegional
TraumaCenterinDnipropetrovsk.

CombatLifesaver(CLS)trainingforalldeployedpersonnelandnewrecruitsmustoccur
immediatelywithadequateIFAKsupplies(pleaseseeANNEXA).TacticalCombat
CasualtyCare(TCCC)ideology,trainingandequipmentmustbepromulgated
throughoutMoD,MoI,volunteerbattalionsandcivicgroupstobecomethestandardof
careandacceptedbyMoDresearchandscientificinstitutes(pleaseseeANNEXB)

Themobilehospitalsrolloutplanissetinthreephases:
1)

TrainingdeploymenttoDnipropetrovsk(practice,scenario,four(4)medical
teamstobetrainedinbestpractices
2)

DeploytoATO/frontlines:integratewithlocalmedicalinfrastructure,provide
emergencywarsurgeryservices,serveasacenterforTCCCmedicaltraining,
CLStrainingandresupply,serveasadisasterpreparednessandmedical
commandstructureforallunitssupportingmedicaloperationsinthe
ATO/frontlines
3)

Redeployasneededtosupportwarfightingactivity

Asamedicalcommandhub,currentlynonexistent,themobilehospitalcantrack
patients,liaisonwithvolunteerunitsforthetrackingofpatients(avolunteerdesk),can

liaisonwithNATOcommandunitsforpotentialfixedwingevacuationandsurge
capacityandwillprovidedailyoversightandoperationalsupporttoallUkrainianmedical
tasks.Thisassetwillalsoserveasamedicallogisticalhubforarrivingdonatedand
statesupportedmedicalsuppliesdistribution.

ThismobilehospitalwillalsoserveasafocalpointforNATOcountrymedicalsupport
andotherprogram

Medicalsupportequipment:
ArmoredHumveesforCASEVAC(40)
Armoredtrackandnontrackvehicles(MRAPs)(40)
Advancedmedicalcommunicationssuite(land,airandsea)multipleunits
GabionHescobarriers(90,000squaremeters)

Considerationofadditionalnonlethalassistanceshouldinclude:
Counterbatteryradars
Unmannedaerialvehicles(UAVs)
ElectroniccountermeasuresforuseagainstopposingUAVs

Conclusion

Theprovisionoffieldhospitalwillgreatlyimprovesurvivabilityrateandpreventionof
preventablebattlefieldrelateddeathandmorbidityfromtrauma.Ukrainehasprovenits
institutionalabilitytoadaptandiscapableofreceiptand,withmanagementsupport,
manageandtakeoverinasustainablemanner,thelistedanddescribedassets.These
requestscancomedirectlyfromtheUkrainiangovernment,theMoDoritsaffiliated
bodies(MedicalDirectorate)ifneedbe.

Medsanbathaveestablishedacombatmedicprogramcurrentlybeingabsorbedby
MoDtobesustainableandinstitutional.Theprogramhasincreasedthemedical
capacityofMoD,MoI,MoH,volunteerunitsandcivilorganizations(police,border
guards,teachersandfirefighters).Thisprogramisnotonlyimpactingmedicalcareon
thebattlefieldandinregionalhospitalsthroughoutUkraine,italsooffersUkrainiansa
tasteofstandardizedcare,anorganizedapproachtomedicalmanagementandhas
beenaccepted,welcomedandpraisedacrosssectorsandpopulations.Medsanbat
SurveyMonkeydataforover800studentsconcludethatthissystemandapproachare
winningtheheartsandmindsofstudents.Theabovementionedpolicyand
programmingcancontinuethisframeshifttoamedicalandpolicystandard.

Medsanbatremainakeypartnerandinclusivestakeholderseekingtoincrease
healthcareoutcomesforUkrainiansoldiersandallcivilians,increasehealthsecurityfor
Ukraine,offerbestpracticesandpromoteTCCCandAmericanbasedemergency
medicinepractices.

Disclaimer
ThesedataarebasedonmultipleATOvisitsandtrainingiterationsandreportsfrom
medicaldirectorsinthefield.TheauthorsworkforMedsanbat(
medsanbat.info
).The
authorscommentsandopinionsareentirelyoftheirownanddonotreflecttheUS
government,anyofitsaffiliationsordepartmentsoranyassociatedpolicywithany
governmentofanykind,whatsoever.Theauthorsopinionsareentirelytheirownand
donotreflectofficialorunofficialpolicyoropinionofMedsanabtorthatofitsguarantors.

Reference
:HospitalMap(updatedMarch2015stakeholderandassetmappinginthe
ATO))
https://www.google.com/maps/d/edit?mid=z0igp8EihJ08.ksgnuRmI5318

ANNEXA

Combat Lifesaver (CLS) Supplies (quantities are literally in the thousands and tens of
thousandsrequired,therequestedamountis,asmanyaspossible):

CATtourniquet

IsraeliTraumaBandage

PillPack

Diclofenac75mg(1)

Paracetamol500mg(2)

Ceftriaxone500mg(2)

GlovePack

LubricatingJellyPacket

NasopharyngealAirway

HaloChestSeal

Decompression14GNeedle

Traumashears

QuikclotCombatGauze

ANNEXB

Combat Medic Medical Supplies quantities are literally in the thousands and tens of
thousandsrequired,therequestedamountis,asmanyaspossible):

HALOChestSeal(5)

GuedelAirway(Oropharyngeal)size3(1)

GuedelAirway(Oropharyngeal)size4(1)

MicroPocketBVM(1)

Portexbluelinetracheostomytube6.0mmcuffed(1)

NasopharyngealAirwaysize6(1)

NasopharyngealAirwaysize7(1)

NasopharyngealAirwaysize8(1)

CatheterMount(Portex)PlainElbowExtendable(1)

igelSupraglotticAirway,LargeAdultsize5(1)

igelSupraglotticAirway,MediumAdult,size4(1)

Waterjelburndressing10cmx10cm(1)

WaterJelBurnGelSqueezeBottle120ml(1)

SleekTape2.5cm(1)

SteriStrip6mmx75mm,packof3(2)

Jelonetparaffindressing5x5cm,Single(5)

Plaster,WashproofHypoAllergenic,20pk,Assorted(1)

GauzeSwabsSterileNonWoven7.5cmx7.5cm5pk(10)

QuikClotCombatGauze(10)

KerlixLargeGauzeRoll(2)

C.A.T.CombatApplicationTourniquet,Black(2)

ARSDecompressionNeedle(4)

Ashermanchestseal,individual(2)

LittmannClassicIIS.E.StethoscopeBlack(1)

Kendricktractiondevice,Original(KTD)(1)

SAMSplint,AdultGrey(1)

LaerdalStifneckSelectCollar,Adult(1)

IntravenousIVSolutionInfusionSetGravity20Drops(4)

500mlNS9%Bag(4)

Hextend500mlBag(2)

Cannula14g(Brown),single(4)

Cannula16g(Grey),Single(4)

Cannula18g(Green),Single(10)

Cannula20g(Pink),Single(4)

Tourniquet,QuickRelease,Adult,Red(1)

EndotrachealTube,Cuffed,size6.0mm(1)

EndotrachealTube,Cuffed,size6.5mm(1)

EndotrachealTube,Cuffed,size7.0mm(1)

EndotrachealTube,Cuffed,size7.5mm(1)

EndotrachealTube,Cuffed,size8.0mm(1)

TrachealTubeIntroducerwithCoudeTip15CH700mmeach(1)

SuturePackSterile,Bronze(1)

Mersilk3/0,Suture(5)

Mersilk5/0Suture(5)

igelSupraglotticAirway,SmallAdult,size3(1)

FirstCareEmergencyBandage6"(5)

Biohazard/ClinicalWasteDisposalBags27cmx46cm(1)

5.11RUSH72Backpack,TacOD(1)

AccuCheckAvivaGlucoseTestStrips(packof50)(1)

FastClixLancets204(1)

PenlightPupilGauge,Disposable(1)

SurgicalSkinMarkerPen(1)

AccuChekAvivaBloodGlucometer(1)

Pockitstretcher(1)

TraumaShears,Large,Black(2)

ScissorsBlunt/Sharp(1)

SpencerWellsArteryForcepsLarge20cm(1)

PetzlTactikkaPlus(1)

LightStick8Hour,6"Yellow(1)

LightStick8Hour,6",Green(1)

LightStick8Hour,6"Orange(1)

AmpouleHardCasetoCarry48,Black(1)

HypodermicNeedle21g1.5"each(3)

HypodermicNeedle23geach(4)

HypodermicNeedle25geach(3)

UltraFineInsulinSyringes(3)

Vitalographemergencysuctiondevice(1)

SuctionTubing,Single(1metre)(1)

SuctionCatheterYankauer(1)

NasogastricRylestube18F(2)

Sphygmomanometers,portable(AdultBPCuff)(1)

FirstCareAbdominalBandagewithpressurebar(1)

WoundstopPro4"(1)

BurnsSheet90cmx120cm(1)

AquagelLubricatingJelly5gSachet(3)

Crepebandage15cmx4.5m

TriangularbandageCalicoHemmedApprox95cmx135cm(3)

Burnscling(2)

Laryngoscopesetwithblades3&4(1)

Scalpelsize10,single(2)

Chesttube(2)

PulseOximeter(1)

FAST1IntraosseousInfusionSystem(5)

SKEDCOstretchers

TalonStretchers

EndReport

[1]Asdescribedin:EmergencyWarSurgery2014,OfficeoftheSurgeonGeneral,BordenInstitute,USA
pages1728

[2]Daalder,I.,Flournoy,M.,Herbst,J.,Lodal,J.,Pifer,S.,Stavridis,J.,Talbott,S.,Wald,S.(2015)
PreservingUkrainesIndependence,ResistingRussianAggression:WhattheUnitedStatesandNATO
MustDo.
TheAtlanticCounciloftheUnitedStates,
February2015.

BattleofDebaltseveJan.2015
https://en.wikipedia.org/wiki/Battle_of_Debaltseve

The'toughasnails'medicsonUkraine'sbloodyfrontlinesFeb2015
http://mashable.com/2015/02/05/medicsonukrainefrontlines/#fvYPEtYQzuqT