SnapshotAssessmentATOTacticalFieldCareandBattlefieldEvacuation

Dec.2014Jan.2015

(photocredit:Chellew)

TheescalatingviolenceoccurringthroughoutthewarineasternUkraineishighlightingthemajorgapsin
emergencymedicalservicesanddisasterresponse.DespitesomeinroadsandprogressbytheMinistryof
Defense(MoD),MInistryofInterior(MoI),SecurityServicesofUkraine(SBU),BorderGuardsandother
volunteerbattalions,bestmedicalpractices,allocationofresources,lackofcommunicationsandoverall
interoperabilitysimplydonotexistandciviliansandwarfightersareexperiencingincreasedmorbidityand
mortalityasadirectresult.ThegoodnewsisthattreatmentisoftenfasterandevacuationstoLevelII
treatmentisrelativelypromptcomparedwiththeonsetofthewarinsummer2014.Thebadnewsisthat
manymilitaryandvolunteerunitsstilllackbasicmedicalequipment,transportunitsvaryinreliabilityand
equipmentandlackarmour,andmanyofthereceivinghospitalsdonothaveadequatesupporttoprovide
themedicalcareandsurgicalinterventionsrequiredforinjuredwarfightersandciviliansalike.CombatMedic
tacticalfieldbagsandequipment/IndividualFirstAidKits(IFAK)arereachingsomewarfightersandcivic
groupsbutmanyactivewarfightersandthosecaughtinthemiddleofviolencesimplyhavenotraining,no
equipmentandnomeanstomitigatepreventabledeathandmorbidity.

Asaresult,additionaltacticalfieldcareequipment/combatmedicbagsandtrainingshouldbeconcentrated
intheNorthernsectoroftheAntiTerroristOperation(ATO)withadditionaltrainingandsuppliesinthe
westernandsouthernregions.TheATOhasnowbeendividedintofoursectors(A,B,CandM)witha
MedicalGroupleaderforeachsectorandan
insitu
medicalcommandeeroverseeingtheentireregion.
DuringthisSnapshotAssessmenttheassessmentteamvisitedwithrepresentativesfromtheDonetsk
AirportCyborgs,the93rd,95th,80th,73rdand25thalongwithmedicalsupportfortheNationalGuardand

InteriorMinistrypersonnel,volunteersandthemedicalunitcommandersfortheentireMoDsupportedarea
oftheATO.Thisreporthighlightsthegapsandshortcomingsthatneedtobeaddressedtostoppreventable
deathonthebattlefieldandconclusionsprovidedoffermultiplecivilianandgovernmentalapplications.

CurrentUkraineMoDMedicalPlan
CurrentlytacticalfieldcareandevacuationisbasedontheSovietsystemofa"FiveStageEvacuation"
whichisappliedcurrentlytoMoDunitsintheATO.

Firststage
BuddyAidwitholdstyledressingandredelastictourniquet(within15minutes)
Availablestandardequipment:
ArubbertourniquetforeachUkrainiansoldier.
Twoindividualbandagepacks(mostlyproducedfortheSovietmilitary).
Painmanagement(usuallyaninjectionofsyntheticopioidanalgesicsuchas
Butorphanolor
Nalbuphin
).
Evacuation:
1)callformedicalvehiclesor
2)evacuateonanyvehicleavailable.

Stage2
.PreMDaid:Saninstructor/feldsherbasicfirstaid
Stabilizethepatient,usuallyprovidedinmaincamp.Theyareattemptingtoassignasaninstructoror
feldsheratallblockposts(i.e.checkpoints).
(Inmanycasessaninstructorsarepeoplewithnomedical
backgroundthatweregiventhispositionduetothelackofqualifiedsaninstructors/feldshers)
.

Stage3
.MDaid
Mobilebrigadesofdoctorsandnurses,usuallyinmaincamp.Usuallytakesabout2hourstogettothis
level.
(EveryBrigadehasamedicalteambutqualificationsvarywithdoctorsofanybackgroundexpected
totreattraumaticinjurieswithlittleornotraumatrainingandequipment).

Stage4
.Hospital
Mobilehospital,civilhospitalorstaticmilitaryhospital(takesabout34hours).
ThisisoftenLevelIIcareat
poorlysupportedcivilianfacilitiesthatrelyonvolunteerstosupplementresources.
24houraccessis
limited,noCToradvancedimagingareavailableandinsomefacilitiesaccesstoIVantibioticsmaybe
limited.Allnoncommunicablediseases(NCDs)arecompletelydepleted(averageageofvolunteerbattalion
fightersiswellabove30yearsofage).

Stage5
.
Rear (Level IV care per NATO standards*). At present the only two centers outside Kyiv that
provide this tier are in Kharkiv and Dnipropetrovsk. Access to neuro and/or vascular surgery is not 24/7
at a few hospitals in the ATO.
Neurosurgery,ophthalmology,advancedreferralspecialitiesetc.Assoonasthepatienthasbeen
stabilized.Patientsareoftenarrivingthesamedayifahelicopterisabletoaccessthehospitalfor
evacuationtoMechnikovaorKharkiv.

Note:
Oneofthemorecontroversialaspectsofthisevacuationplanisthatpatientsaretobebroughtbacktothe
unitsmaincampwhereadoctorisstationed.Onceincampthedoctorprovidesaidanddeterminestheneed
forhigherlevelofcare.Atthispointifthedoctorsassessestheneedforhighlevelofcare,thepatientis
againloadedintoavehicleandtransportedtoahospital.Thisofcourseaddsunnecessarydelayandin
somecasesactuallymovesthepatientawayfromhigherlevelofcare.

Hospitals(*BasedonNATOStratificationofHospitalSupport)
Duetothemilitaryandcivilianhealthcareinfrastructure,100%ofthewarfightingandcivilianinjuriesprocess
throughacivilianhospitalatsomepointduringtheircarethereispresentlynoformalcommunication
processtotrackorproperlyallocateresourcestoprovidesurgecapacityintimesofmasscasualty.
LevelIV
DnepropetrovsksMechnikovaCivilianHospital,KyivMilitaryHospital,OdesaMilitaryHospital,Kharkiv
MilitaryHospital,LvivMilitaryHospitalandVinnytsiaMilitaryHospital.AllareconsideredbytheUkrainian
MilitaryasLevelIVfacilitieswithtraumacare.Mechnikova,acivilianhospital,isprobablythebestandonly
onethatcouldquicklyreceiveinternationalrecognitionasaLevelITraumaCenter(NATOLevelIV)

LevelIII
NotcurrentlyavailablewithintheATOwithanyconsistency.Forexample,MariupolHospitalhadan
extremelyhypotensivepatientwithavascularinjuryintheleg.Avascularshuntwasrequiredandhadtobe
transportedfromZaporizhiatoMariupolbeforethesurgerycouldbecompleted.

LevelII
ImpactedcivilianhospitalsreceivingcasualtiesfromtheATO(Anyclinicorhospitalcananddoesreceive
victimsbuttheselistedbelowarecurrentlythetopreceiversfromactionsintheATO).Allhospitalsarebasic
hospitalswithlimitedsurgicalabilities,nocomputerisedtomography(
CT
)scan,somehavexrayequipment
fromthe1950sand60sonlyinoperationandnobloodbankaccessnonecouldbeconsideredatrauma
facility.Allthesefacilitieshavemaderequestsforadditionalassistancesuchasstaffingorequipmentbut
responseisoftenslow.Oftentheyfindtheironlyimmediatesupportisfromvolunteergroupssuchas
EuroArmyMaydan
and
UkrArmy.org

LevelIIHospitals:
Kurakhove,Dymytrov,Selydove,Volnovakha,Krasnoarmiis'k,Mariupol,Starobil's'k,
Artemivs'k,Debal'tseve,Shchastya(CTavailableatMariupol,KrasnoarmiiskandArtemivsk).Foradditional
hospitalsandupdatedstatusvisitMedicalATOGoogleMap:
https://www.google.com/maps/d/edit?mid=z0igp8EihJ08.ksgnuRmI5318&usp=sharing

MajormedicalreceivingpointsintheUkrainiancontrolledATO

BaseofATOHQ,MedicalOperationsandmobilehospital
Kramatorsk
(previouslocation:
Izyum)
Locatedatasmallairportontheedgeofthecityinasemisecurecompound.Consistsofalandingfieldfor
theirmedevac,asmallclinicwithabout40bedsandasmallsurgicalunitthatwasoncelocatedinIzyum.
MostlyseesmedicalpatientsandhasnocurrentmedicalvalueforemergentinjuriesfromwithintheATO.

ATOMedicalOperationsandmobilehospital
Kramatorsk
(photocredit:Chellew)

MilitaryMobileHospitals.
Itappearsthatmostofthepatientsaretransported,inalargepercentageof
cases,totheclosestbasichospitalinthearea.Thisisanexcellentsolutiontoafluidsituationexceptthat
manyofthesehospitalsarenotpreparedandnotreceivingimmediatesupportfromtheMinistryofHealth,
theMinistryofDefenceorinternationalplayers.Oftenthesehospitalwhenimpactedwillreceivehelpfrom
volunteerdoctors/surgeonsandmilitarydoctorsbutthereappearstobenocentralauthority(Bestledmy
MoDandMoH)tohelpregulateandassist.

For those hospitals in areas where there is act

ualshellingorfighting,staffingitisextremelydifficultgiven
thecivilianworkersoftenleavetheareafortheirownsafety.ThetwoMobileMilitaryhospital,the59thand
the61th,nowinKurakhovo,werenotincludedinthisassessmentsincethelargemajorityofpatientsthat
wereseenintheareasvisitedwereevacuatedthroughcivilianhospitals.Medicalelementsofthe80thwere
largelysupportingtheNorthernsector,the25th,79th,93rdand95thsupportingthewesternandsouthern
sectorsandBattalionKyivIIwassupporting
Volnovakhaandinstrumentalintreatingthevictimsofabus

attackontheoutskirtsofthecitythat
resultedinthedeathsof12passengersofanintercitybusandinjuries
to18othersinthearea
.ManycitiesinandneartheATOaresupportedbyunitsoftheInteriorMinistryand
NationalGuar
d. Mariupol Airport was visited on a previous trip in early December where patients are

transferred from Mariupol Hospital and medevac to Mechnikova. The airport also contains a small
outpatient clinic.

All units visited have some form of official or unofficial medical support but consistency varies largely,
with many units struggling with Volunteer Medics, little or no medical equipment and if they do, it is
usually the result of volunteer donor support. The level of medical support was usually Stage 1 through
III based on the existing post Soviet military medical system. Medical support (Ukr Stage 4) was usually
provided by any local hospital until arrangement could be made to get the injured party to
Dnepropetrovsks Mechnikova Civilian or Kharkiv Military Hospital for Ukr Stage 5 care. There have been
many attempt by civilian elements to staff a mobile hospital in the ATO but without proper
equipment and personnel and with limited success. For example one recent volunteer unit set up in the
city of
Kurakhovebutaftertwoweeksofreportedlylittleusereturnedtothewesternregionstoawaitfora
newdeployment.

ProposedlocationstoincreaseorcomplementtoinordermeetNATOstandardLevelIII
medicalcare
TherestillremainsaneedforfullyfunctionalLevelIIImobilehospitalintheATO.Thetermmobileshould
notbeinterpretedsolelyasoutdoorandinatent,butinsteaditisaresourcethathastheabilitytoquickly
movefromonelocation,fixedorportable,withtheequipmentandstaffnecessarytoelevatethecapacityof
alocalhospitalorareaforboththemilitaryandcivilianpopulation.
Thethreebestlocationforamodernmobilefacilityare:
1) IntheSouth,MariupolAirportorhospital.AlreadysecuredbyUkrforcesandonlyrequires
additionalsecurityalongthesmallsectionoflandbetweentheairportandtheBlackSea.Then
flightscouldapproachbyseawhereitisconsiderablylesslikelytobetakendownwithportableanti
aircraftmissiles.SecuringtheareawouldnowopentheATOforevacuationbyUkrainesAnton26
CriticalCare(CCT)aircraftandhelicopters.Evacuationfromhereiscurrentlywithhelicopterto
either
Dnepropetrovsks
MechnikovaorZaporizhiaRegionalHospital.Civilianmedevacis
nonexistentandtransportbygroundisexceedinglydifficulttoahigherlevelofcare.

MariupolInternationalAirport

2) Thesecondlocationis
Krasnoarmiis'k.Thecityboaststhreehospitalandbetweenthethreethey
canmoreorlessbeconsideredaLevelIIIlocation.Buteachhospitalhasitstrongpointsanditis
difficultforanarrivingunittoknowforsurewhichhospitalwouldbebestforaninjuredpatient.Most
localobserversconsiderthehospitalleastavailabletoacceptalsothebestequippedforemergency
treatment.ThehospitaliscurrentlymanagedbytheUkrainianRailWorkersUnionandnotregulated
ormanagedbytheMoHorMoD.MostofthepatientsarrivinginKrasnoarmiis'kfromthefightingin
DonetskcomethroughthiscityforinitialorsecondarytreatmentbeforemovingtoDnepropetrovsks
MechnikovaHospital.ManyofthemilitarycasualtiesareoftenMedevacdatthispointbutthe
infrastructuretoairliftciviliancasualtiesisnotavailable..Patientsin
Krasnoarmiis'k
areoftenfirst
seenatforwardhospitalssuchas
Selydovewhichoftenlacksuppliesandstafftostabilizepatients
forthenextmovethroughthechain.Again
civilianairmedevacisnonexistentandtransportby
groundisexceedinglydifficulttoahigherlevelofcare.

Krasnoarmiis'kisstrategicallyplacedto(anddoes)receivevictimsintheWesternRegionandisthe
majortransitpointforinjuredwarfightersfromthefightingnearandaroundDonetskAirport.

3)
ThethirdlocationisnorthofShchastyaandDebal'tsevewheremilitarypatientsarelaterevacuatedto
Starobil's'kandArtemivs'kandeventuallytoKharkiv.BothShchastyaandDebal'tseveareindireneedof
additionalmedicalresourcesandtraining.Thisareaprovestobeoneoftheworstforgroundevacuationand
thesetwocitiesaredirectlycutofffromeachotherbyinsurgentactivityinAlchevsk.Althoughmostpatients
inthenorthernregionoftheATOgotoKharkiv,itisalongandconvolutedrouteoftenthroughaseriesof
hospitals.Eachcityrequiresanddoeshavesomelevelofaforwardsurgicalunitintheseexisting
hospitals,butaregionalreceivingpointwithairaccessissorelyrequiredfortheciviliansandwarfighters.It
alsoshouldbenotedthatflighttimesarealmostequalbetweenKharkivandDnipropetrovskandserious
considerationshouldbemadetouseDnipropetrovskastheprimaryfacilityandKharkivasasecondary
location.Althoughasitehasnotbeenlocated,somethingwithairsupportandLevelIIIcareandgood
accessisessentialtoreducethelongandconvolutedtransporttimesrequiredtomovepatientstoKharkiv.
Again
civilianmedevacisnonexistentandtransportbygroundisexceedinglydifficulttoahigherlevelof
care.

Northernregionislargeandmostlyrural

Dnepropetrovsks
MechnikovaHospital/AirTransport

Map:Dnepropetrovsks
MechnikovaHospitalandSlavutychStadium

Aquicknoteworthyofrepeating,DnepropetrovsksMechnikovaHospitalisthebesthospitalintheEastand
arguablyinUkraine.Althoughtherehasbeenrepeatedtalkaboutplacingahelicopterlandingpadatthis
hospital,sofartherehasbeenlittlemovement.AnideallocationistheSlavutychStadiumlocatednextto
thehospital.Thisideaneedstobepushedforward,itsissomethingthehospitaladministrationagreesto
anditalsocouldaugmentandincreaseciviliancasualtiesarrivingfromtheATO.
Thisbringsupanadditionalpoint:theuseof
www.ukrcopter.com/en/
withtheirfullALS/CCTMi8helicopters
toevacuatewoundedvictimsfromtheunderstaffedandimpactedlocalhospitalsdirectlytoMechnikova.
ThisUkrainiancompanyshouldbeemployedforimmediateusetohelpevacuatecasualtiesfromthe
affectedhospitalintheATO.TheyhavebeenutilizedbeforebytheUNandICRConnumerousoccasionin
AfricaandSouthAmericaandhaveaproventrackrecordandexpertise.

Groundtransport
Ambulancetransportationcontinuestobeanissue.Theclosertocombatthemoredismalitbecomes.Most
ambulanceseenbythisobserverhavelittleornoequipment,manyarewithoutproperheating.Thebetter
equippedambulanceareoftenusedforinterfacilitytransportfromATOoutlyingimpactedhospitalsuchas
Krasnoarmiis'kandArtemivs'k
toKharkivandDnipropetrovsk.Manyambulancesaredonatedbyvolunteer
groupsandvolunteersandmilitarypersonnelstafftheunits.Repairingandequippingisoftendoneby
volunteers.Forexample,theambulancepicturedbelow,hasseenmorethanitshareofaction,wasused
duringthesiegeofLuganskAirport,itsdriverwascapturedandlaterreleased.Todaythisvolunteer
continuestobeg,borrowandstealtokeepitupandrunningandstillconsistentlyusedtomovepatients
fromcombatareassuchas
Shchastya.

Volunteerambulanceonthewayto
Shchastya
(photocredit:Chellew)

FromDonetskAirportpatientsareevacuatedbyanyavailableArmoredPersonnelCarrier(APC)toa
locationnearPiskywherethepatientsarethentransferredtosoftskinciviliantypeambulanceswithlimited
equipmentorprivatevehiclesfortransportto
Selydoveand/orKrasnoarmiis'k.

Thereisanimmediateneedforarmoredplated,medicstaffedandequippedambulancesinPiskyandevery
otherareawithactiveshelling/fighting.Thislackofsuitable,wellequippedandproperlystaffedambulances
isrepeatedthroughouttheATO.Thereisplentyofanecdotalandnotyetpublisheddatathatlackof
armouredmedicaltransporthasledtomanydeaths.

AirMedevac
AirtransportwasnotseenduringourmostrecenttimeintheATO.Therehasbeenreportsofsome
additionalequipmentprovidedforthehelicopterssinceourlastvisit,buttheseaircraftinservicearenot
designedformedicaluse.EstablishingacontractwithUkrainianHelicopters
www.ukrcopter.com/en/

should
beapriorityforimmediateimprovementuntilthemilitaryisabletoprovidedmedevacsthatmeetsome,ifnot
allinternationalstandards.

EvacuationfromthefrontlinesisnolongerdonebyhelicopteraftertheintroductionintotheATOof
Manpadsduringthesummermonthsof2014byRussianforces.Patientsaremovebygroundtoalocal
hospitalwheretheyarestabilizedandthentheseriouspatientsaretransportedtoKharkivor
Dnipropetrovskabyhelicopter.

DuringtheearlydaysoffightingintheATO
andaccordingtoestimates,Ukrainehaslost18aircraftand
helicopters,killing89people,11wereinjuredandtwomissing.Thelostincluded10helicopters(fiveMi8
andMi24)andeightaircraft(AN30B,An26,Il76andtwoMiG29andtwoSu25,Su24M).Themost
seriouswasthedestructionofamilitarytransportIl76onJune14(49persons),accidentsandfiveMi826
people.ThemostsignificantmaterialdamagetothestatewasthecrashoftheMi24(5h1575million)and
MiG29(2h3060milliondollars).additionally,
MalaysiaAirlinesFlight17(MH17/MAS17)[a]
wasa
scheduledinternationalpassengerflightfromAmsterdamtoKualaLumpurthatcrashedon
17July2014
,
havingbeenshotdownoverUkrainebyRussianforces,killingall283passengersand15crewonboard.

Communication
Stillanissuewiththeuseofunsecuredcellphonestheprimarymeansofcommunication.Establishmentof
asecurecommunicationnetworkremainsacriticalpriorityalongwithaCentralMedicalCommandcenter
(pleaseseebelow).

MedicalCommandandControl

Improvementseenbutthesupportstaffstilllacksmodernmedicalandadministrativeequipment,
communicationtools,ALSambulances,medevacs,armouredplatedambulances(APC)andsupport
vehicles.Medicalpreplanningisreallytheresultofareactiveresponsetothecurrentemergency
requirement.ThereislittlecooperationseenbetweentheMoDandMoHtomaximiseresourcesintheATO.
SupportfromKyivisviewedasnexttononexistentbymanyofthemilitaryandcivilianmedicalproviderson
thefrontlines.Oneexampleoftheinefficiencyofthemedicalchainofcommandisthesystemfororderinga
medevac.Itsatimeconsuming,telephoneprocedurethatmustgothroughmanylevelsbeforefinallybeing
approved.Inmostcasesthisisauthorizationtopickuppatientsatpreexistinghospitalormobilehospital.A
nondedicatedMi8isthandeployedfromDnipropetrovskaor
Kramatorsktotherequestingfacility.

Theselocationsshouldhaveimmediateradioaccesstohelicoptersthatdonotrequireapproval(just
notification)fromachainofcommand.Becausethesafetyoftheaircraftcannotbeguaranteedduetothe
liberaldispersionofshoulderfiredmissilesbyRussianforces,noaircraftcanbeapprovedforevacuationof
theinjureddirectlyfromafrontlineposition.Buttheuseofpreplannedrallypointswithdirectradioaccess
tomedevaccouldimprovetheevacuationdirectlyto
Dnipropetrovsk.

MilitaryambulancescurrentlyinuseintheATO

MilitaryambulanceonthefrontlinesnearPisky95thAirbornedonatedBLSambulance
(photocredit:Chellew)

Donatedsoftskinfrontline93rdAirborne
ambulancestockwithoneMedsanbatmedicbagand
usedtoevacpatientsfromPisky(DonetskAirport)to
SelydoveHospital.
(photocredit:Chellew)

Newlyoutfittedmedicfromthe95thAirbornewithMedsanbatcombatmedicbag.
(photo
credit:Chellew)

Mi8helicopterconvertedformedevacloadingpatientsatMariupolAirportNov2014
(photocredit:Chellew)

(photocredit:http://dpsu.gov.ua/en/)

ThisBorderGuardarmouredvehiclewasusedtoevaccasualtiesfromablockpostnear
GnutovonortheastofMariupolonJan19th,2015.Ifasoftskinambulancewasusedthe
resultswouldhavebeenprobablyfatalforallastheywerehitwithmortarfireonleaving
thearea.
CombatMedicandEvacuationTrainingforthe79thAirborneandUkrMarinesin
Mykolaiv,Ukraine.Jan30th,2015

ReferenceMaterial

*NATOStratificationofHospitalSupport:

http://www.nato.int/docu/logien/1997/lo1610.htm
RoleSupport

Theterm"Role"or"Echelon"isusedtodescribethestratificationofthefourtiersinwhichmedicalsupportis
organised,onaprogressivebasis,toconducttreatment,evacuation,resupply,andfunctionsessentialtothe
maintenanceofthehealthoftheforce."Echelon"or"Role"isdefinedonthebasisofcapabilitiesandresources,and
isnotspecifictoparticularmedicalunittypes.Theterm"role"isusedbylandorairforces,while"echelon"isprimarily
amaritimeterm.Whilecloselyrelated,theyarenotexactlyinterchangeable.Thetreatmentcapabilityofeach
role/echelonisintrinsicatthehigherlevel,e.g.arole3facilitywillhavetheabilitytocarryoutrole2functions.Each
levelofsupporthastheresponsibilitytoresupplyandotherwisesupportthelevelsbelowthem.Thereisno
requirementthatapatientmustnecessarilypassthrougheachechelonofcareinprogressionduringtreatmentand
evacuation.

Role/Echelon1medicalsupportisthatwhichisintegralorallocatedtoasmallunit,andwillincludethecapabilities
forprovidingfirstaid,immediatelifesavingmeasures,andtriage.Additionally,itwillcontributetothehealthand
wellbeingoftheunitthroughprovisionofguidanceinthepreventionofdisease,nonbattleinjuries,andoperational
stress.Normally,routinesickcallandthemanagementofminorsickandinjuredpersonnelforimmediatereturnto
dutyareafunctionofthislevelofcare.

Role2supportisnormallyprovidedatlargerunitlevel,usuallyofBrigadeorlargersize,thoughitmaybeprovided
fartherforward,dependingupontheoperationalrequirements.Ingeneral,itwillbepreparedtoprovideevacuation
fromRole/Echelon1facilities,triageandresuscitation,treatmentandholdingofpatientsuntiltheycanbereturnedto
dutyorevacuated,andemergencydentaltreatment.Thoughnormallythislevelwillnotincludesurgicalcapabilities,
certainoperationsmayrequiretheiraugmentationwiththecapabilitiestoperformemergencysurgeryandessential
postoperativemanagement.Inthiscase,theywillbeoftenreferredtoasRole2+.Inthemaritimeforces,Echelon2is
equivalenttothelandforces'Role2+,asasurgicalteamisintegraltothisechelon.Maritimeechelon2supportis
normallyfoundonmajorwarvesselsandsomelargerlogisticsorsupportvessels,andatsomeForwardLogistics
Sites(FLS).

Role/Echelon3supportisnormallyprovidedatDivisionlevelandabove.Itincludesadditionalcapabilities,including
specialistdiagnosticresources,specialistsurgicalandmedicalcapabilities,preventivemedicine,foodinspection,
dentistry,andoperationalstressmanagementteamswhennotprovidedatlevel2.Theholdingcapacityofalevel3
facilitywillbesufficienttoallowdiagnosis,treatment,andholdingofthosepatientswhocanreceivetotaltreatment
andbereturnedtodutywithintheevacuationpolicylaiddownbytheForceSurgeonforthetheatre.Classically,this
supportwillbeprovidedbyfieldhospitalsofvarioustypes.MaritimeEchelon3isequivalenttoland/airforcesRole3,
thoughitwillnormallyhaveincreasedspecialtycapabilities.Echelon3isnormallyfoundonsomemajoramphibious
ships,onhospitalships,atFleetHospitals,atsomeFLS,andatafewAdvancedLogisticsSupportSites(ALSS).

Role/Echelon4medicalsupportprovidesdefinitivecareofpatientsforwhomthetreatmentrequiredislongerthanthe
theatreevacuationpolicyorforwhomthecapabilitiesusuallyfoundatrole/echelon3areinadequate.Thiswould
normallycomprisespecialistsurgicalandmedicalprocedures,reconstruction,rehabilitation,andconvalescence.This
levelofcareisusuallyhighlyspecialised,timeconsuming,andnormallyprovidedinthecountryoforigin.Under
unusualcircumstances,thislevelofcaremaybeestablishedinatheatreofoperations.

UkrainianmilitaryaircraftlostintheATO,18aircraftand,killingalmostahundredpeopleUnian
http://www.unian.ua/politics/954326ukrajinskaviyskovaaviatsiyazachasatovtratila18mashinzaginulim
ayjestolyudey.html
ListofUkrainianaircraftlossesduringtheUkrainiancrisis
https://en.wikipedia.org/wiki/List_of_Ukrainian_aircraft_losses_during_the_Ukrainian_crisis

Volnovakhabusattack.Jan13,2015
https://en.wikipedia.org/wiki/Volnovakha_bus_attack

SecondBattleofDonetskAirport
foughtfrom28September2014until21January2015
https://en.wikipedia.org/wiki/Second_Battle_of_Donetsk_Airport