Medical Assessment

Medical Assessment
Ukrainian World Congress

July 28th August 8th 2014
Ukrainian World Congress Medical Assessment
John Quinn, MPH, MD

Medical Consultant
+380685720322; +1 6307479081
cuinne@gmail.com
Ulana Suprun, MD
Director of Humanitarian Initiatives
+380 91 971 6363; +1 347 866 4210
Patrick Chellew, EMT-P
Medical Consultant
chellew.patrick@gmail.com
Table of Contents
LIST OF ABBREVIATIONS
SELECTED MAPS OF UKRAINE
EXECUTIVE SUMMARY
10
KEY FINDINGS AND GAPS

KEY RECOMMENDATIONS AND FURTHER PROGRAMMING
10
10
INTRODUCTION
12
DATA COLLECTION AND METHODOLOGY
12
ASSUMPTIONS
13
RESULTS
13
ACCESS
13
DENIED ACCESS
THE CULTURE OF MEDICINE: UKRAINE
13
14
LIMITATIONS OF STUDY
15
DISCLAIMER
15
MAIN POINTS OF CONTACT THROUGHOUT ASSESSMENT
16
HOSPITAL FACILITIES VISITED
18
SCHEDULE AND TIME TABLE OF ASSESSMENT
18
LOCATIONS VISITED GRAPHICALLY

CLIMATE AND TERRAIN
19
20
BACKGROUND TO CONFLICT
21
THE ENEMY
22
RECENT EVENTS
22
COMBAT TRAUMA: A VERY BRIEF OVERVIEW
23
COMBAT TRAUMA BEST PRACTICES

ROLES AND DESIGNATIONS OF COMBAT CASUALTY CARE TEAMS
SPECIFIC ROLES AND DEFINITIONS
COMBAT LIFESAVER
COMBAT / OPERATOR MEDIC
SPECIAL FORCES / PATROL MEDIC
COMBAT / TACTICAL PHYSICIAN / PARAMEDIC
EMERGENCY ULTRASOUND THE EFAST
24
25
25
25
26
26
26
26
MECHANISMS OF TRAUMA: THE ATO IN ACTION
27
AK-47 AND SMALL ARMS

WHITE PROSPEROUS (WP)
INJURY PATTERNS
SMOKE INHALATION
FUME INHALATION
INFECTIOUS DISEASE AND ILLNESS IN CONFLICTS: A VERY SHORT REVIEW OF ACUTE THREATS
STRESS
COMMUNICATIONS AN OVERVIEW
28
29
29
30
30
30
30
31
MEDICAL EVACUATION
31
ROTARY WING
THE UKRAINIAN EXPERIENCE
FIXED WING
VINNYTSIA
33
33
35
36
EQUIPMENT
36
DR. ANATOLY ANDRONATTI MEDICAL DIRECTOR MEDICAL EVACUATION
39
SITE VISITS
40
MAIN MILITARY HOSPITAL KYIV

IRPIN MILITARY HOSPITAL AND REHABILITATION CENTER
KHARKIV
KHARKIV AIRPORT CLINIC (CIVILIAN)
IZYUM
DNIPROPETROVSK
MAIN MILITARY HOSPITAL IN DNIPROPETROVSK
DNIPROPETROVSK AIRPORT CLINIC
DNIPROPETROVSK CIVILIAN HOSPITAL TRAUMA CENTER
BURN HOSPITAL DNIPROPETROVSK
61ST MOBILE FIELD HOSPITAL
40
41
42
44
45
45
45
46
47
48
49
KEY FINDINGS AND CONCLUSIONS
49
KEY FINDINGS
KEY RECOMMENDATIONS AND URGENT PROGRAMMING
50
50
WORKS CITED
51
ANNEX
52
CONTENTS OF INDIVIDUAL (IMPROVED) FIRST AID AID KIT (IFAK)

53
COMBAT LIFE SAVER (CLS) CURRICULA AND COURSE MATERIALS (UKRAINIAN AND ENGLISH)
53
PRE-EXISTING PROGRAMMING WITH THE IFAK AND UKRAINIAN WORLD CONGRESS
53
SPECIAL FORCES (SF) ADVANCED PARAMEDIC CURRICULUM
53
SPECIAL FORCES (SF) ADVANCED FIELD BAG CONTENTS
53
ALLIED JOINT MEDICAL SUPPORT DOCTRINE AJP-4.10(A) NATO
53
MEDICAL EVALUATION MANUAL AMEDP-27
53
CASUALTY EVACUATION IN THE CONTEMPORARY OPERATING ENVIRONMENT: A MONOGRAPH (LEONA
C. KNIGHT)
53
NATO 9-LINE MEDEVAC
53
List of Abbreviations
ACLS Advanced Cardiac Life Support
APC Armored Personnel Carrier
ATO Antiterrorist Operation, also referred to as theatre of military operations
CLS Combat Life Saver
CAMTS Commission on Accreditation of Medical Transport Systems
CASEVAC casualty evacuation
CDC Centers for Disease Control and Prevention
5
COB Contingency Operating Base

CSH Combat Support Hospital / Combat Surgical Hospital
CT computed tomography
EU European Union
eFAST Expanded Focused Assessment with Sonography in Trauma
FAST Focased Assessment with Sonography in Trauma
FOB Forward Operating Base
IFAK Individual (improved) First Aid Kit
ICRC International Committee of the Red Cross
ICU Intensive Care Unit
ITLS International Trauma Life Support
MEDEVAC medical evacuation
MRI magnetic resonance imaging
MTF Medical Treatment Facility
NATO North Atlantic Treaty Organization
NCD non-communicable disease
OCHA United Nations Office for the Coordination of Humanitarian Affairs
PHTLS Prehospital emergency trauma life support
POC Point of Contact
PPE Personal Protective Equipment
PTSD Post traumatic stress disorder
SBU Security Service of Ukraine
SF Special Forces
WHO World Health Organization
WP white phosphorous
Selected Maps of Ukraine
The map above denotes clear military estimations by other countries this data has
not been verified. The main map of Ukraine is illustrative in nature and provides the
main cities and regional context.
The map above was taken from the Ukraine Crisis website and details the estimated
areas of operations as of September 3rd, 2014. There are significant violent activities
displacing many civilians.
Executive Summary
Ukraine has undergone a social and political revolution with violence. At present, there
is an active anti terrorist operation (ATO) by Ukrainian military and other actors
against well-supplied separatists, mercenaries, Russian Federation troops and
terrorists in Lugansk, Donetsk and other regional hubs such as Mariupol and others.
This snapshot assessment aims to describe medical evacuation and emergency
medical care from point of injury within the ATO of a Ukrainian soldier to receipt at a
tertiary care and receiving medical facility. This report is not exhaustive, only was
undertaken over the course of 12 days and is only the start of what a comprehensive
medical audit can cover with data collection and process observation that is facilitated
and supported by the Ministry of Defense. The gaps observed and highlighted with
key recommendations are summarized below.
Key findings and gaps
The anecdotal average time from point of injury of a soldier to first medical
contact is 20 60 minutes
The anecdotal average time from point of injury to field hospital with surgical
capability is 12 to 18 hours (in some instanced as long as two days)
Soft and durable surgical supplies in the ATO are inadequate for high patient
volume, inclement weather and some trauma patient presentations
Mobile hospitals visited are completely inadequate for adverse weather,
prolonged conflict or medical operations to fit into an international standard
The rotary aircraft used for medical evacuation is not fit for purpose, daily
operations of evacuation are dangerous and currently may further delay in
patient care and may cause further injury
Individual first aid kits (IFAKs) to an international standard for each soldier with
accompanied CLS training is at less than 1% of uniformed troops
The special forces medic role with advanced trauma treatment capabilities in
the field is non-existent
The golden hour of trauma and current best practices in emergency medicine
are not uniformly followed across specialties or military facilities that were
visited
At the writing of this report, there are no armored ambulance transport
capabilities to transport patients from active combat areas to casualty
evacuation points
Communicable disease such as polio and tetanus present a clear and present
threat across the ATO and all of Eastern Ukraine with inadequate access to
prevention and vaccination, and poor hygiene and basic services access
Key Recommendations and further programming
All active duty Ukrainian military are to be issued an individual first aid kit (IFAK)
and receive appropriate Combat Life Saver (CLS) training
An injection of copious amounts of field dressings, pressure dressings, updated
tourniquets and airway adjuncts to the mobile hospitals for re-supply of mobile
medical teams and brigade level medical staff re-supply is acute and greatly
needed
Re-usable surgical instruments, c-arm x-ray equipment and modern anesthesia
machines for field hospitals and medical facilities supporting the ATO are
required
9
20 portable ultrasound devices and adequate training for medical staff to carryout a eFAST to assist with triage and transport decisions should be implemented
for mobile brigade level doctors and paramedics and mobile hospitals in the ATO
Eliminate the in situ mobile hospitals 59th and 61st and replace with modern field
hospitals with updated surgical capabilities, emergency medical care,
diagnostics, life support facilities and weatherproofing these mobile hospitals
should be strategically placed to serve as combat support hospitals, have rotary
winged aircraft access, be in a highly defensible position and have encrypted
communication access to regional and central medical support
All doctors, nurses and medics working at the mobile field hospitals are to be at
or above the following standard:
o Train and practice to the International Trauma Life Support (ITLS) /
Advanced Trauma Life Support (ATLS) standards
o Conduct emergency medical management of trauma, triage, patient
assessment and re-assessment of patients upon arrival from the field /
smaller facility
o Be proficient with continuity of care rendered in the field to the CLS core
management principles and advanced practices
o Follow the concepts and methodology behind the Golden Hour of trauma
management
Civilian rotary medical evacuation aircraft need to be purchased or contracted
for use throughout the ATO to transport the critically ill and injured following
CAMTS guidelines
300 to 500 current combat medic / medical doctors to be trained in the Special
Forces medic role with advanced medical bag and equipment
Dedicate and configure four (4) APCs to function as armored ambulance
transport from active combat area to casualty evacuation point
Procure adequate supplies of the polio and tetanus vaccines for use throughout
the civilian, enemy and Ukrainian populations in the East
The medical administration office and Ministry of Defense (please see schematic
in illustration further in this report) need to make a clear message to the
international community what they want, what they think they need and what
they will do if given assistance.
Specifically, The Medical Administration and Ministry of Defense need to:
o Broadcast in a single voice the humanitarian and medical requirements by
donors and the international community to carry out their core mission(to
define a core mission if not already done so)
o Such marketing strategies that clearly define their needs with evidence
and internal audit and data collection and specifically what resource
requirements are lacking and which mission essential equipment are
needed to complete their mission
Finally, a communication between the enemy and Ukrainian military about cross
border medical care and access needs to be established. This line of
communication needs to be between top level decision makers and have the
tone of humanitarian support to enable best practices and outcomes for
patients for an enemy that may not consider either
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Introduction
The Ukrainian World Congress is producing this assessment report for the Ukrainian
Ministry of Defense as an independent review of the emergency medical services
offered by the military for the casualties received from the Anti-terrorist Operation
(ATO). This independent review is objective in nature, chooses no sides of the conflict
and is descriptive. The findings of this research and assessment are the property of
the Ukrainian World Congress and may provide more details of gaps and areas for
future programming by the Ministry, donors and other governmental agencies.
The description of the process of medical evacuation juxtaposed to international and
North Atlantic Treaty Organization (NATO) standards highlights current gaps.
Conclusions of this assessment set fourth potential measures and programming to fill
these gaps and make medical evacuation, emergency medical care and prevention
more robust against prolonged conflict and locally sustainable.
Data collection and Methodology

This descriptive study defines loosely the current practices of the Ministry of Defense
for its troops from point of injury to receiving definitive care, where the main assessor
was allowed access. This assessment was carried out from July 28th to August 8th, and
included interviews, site visits, patient record review, military and security services
medical training audits, stakeholder mapping, a brief review of programming in place,
discussions with donors and field visits to secondary locations.
Odesa and Lviv are key medical players in medical treatment, surgery and
rehabilitation of injured troops. However, due to time restraints, these medical cities
and infrastructure were not visited or contacted. Crimea is presently under
occupation by Russia and once held a major component of neurological injury
treatment and rehabilitation programs for the Ukrainian military; these facilities were
not visited.
The State Emergency Department of Ukraine would not grant us permission to speak
with the Head or Deputy Head of it organization. Email was sent but no reply. Due to
Ukrainian troops being treated within the Russian Federation, outreach to the
Ukrainian Consulate in Rostov was barred via telephone in attempts to gaining more
information about the medical treatment process in Russia. Phone calls and email
were sent to the Ministry of Foreign Affairs of Russia requesting a medical assessment
and appraisal of the facilities that rendered treatment to these troops or a policy
statement; as of the drafting of this report no message from Russia was received.
Data collection is qualitative. There is presently no official audit or quantitative
collection of ATO specific patient information by the Ministry of Defense. All data
referred to in this report are anecdotal and offered by the treating physician and
medical director on site. All estimated incidence and prevalence, unless otherwise
cited, is an estimate and should be treated as such. The notes and photos taken in
this study were uploaded 1 week after collection and data can be lost or skewed.
Some images were captured by other sources other than the main assessor and are
cited as such. In some instances, images are taken from open source material or sent
11
by local actors on the ground when access for the assessment team was not
permitted.
The primary language of the main assessor and author of this report is English. All
communication with contacts and sites were conducted via translation and
interpretation from Ukrainian and Russian into English. As with any amateur
interpretation, nuance may be lost, some medical vocabulary did not translate well
and some English terminology related to medical practice, best practices and military
related may have translated poorly.
Assumptions
Much of the data collected was from direct source. However, not all data and
information could be verified, checked and crosschecked. Inherently in war fighting
activities, there is a fluid atmosphere and information flow may be direct or
convoluted and correct or dynamic. All efforts were made to verify all information
offered by primary sources.
Assumption with this type of data collection purports that no new medical assets
developed during the time of the assessment, that we had access to all of the
functioning de facto or ad hoc medical assets and that all interviewed and observed
medical staff functioning and working in hospitals and locations visited have adequate
and accurate information about their facilities to offer.
Results
The results for this assessment are twofold. The first is a set of objective photos and
illustrations taken while on assessment. These photos and illustrations are then
commented on with notes and data. These illustrations and photos serve as the actual
snapshot of this assessment to allow decision makers and policy makers to see some
major elements of the evacuation chain. These results are then concluded upon by
identifying gaps with clear, practical and plausible stopgaps in the form of new
programming.
Access
The Security Service of Ukraine (SBU) provided limited access to facilities and the
ATO. The Medical Administration Department also offered very little access to medical
facilities and was obstructive in nature for any fact finding for the process of point of
injury to points of care for the ill and injured in the ATO. In some instances this
obstructive nature not only blocked our access to medical facilities and processes, it
also hindered the ability of the assessment team to clearly observe the medical
evacuation process, appropriately take notes or adequately describe this process.
Access across military and key medical infrastructure in times of war is problematic.
The government inherited security, police and defense structures that had by accident
or design almost ceased to exist under the deposed president; many diplomats
describe the military leadership as dysfunctional. Senior officials are difficult to
contact and fail to articulate what assistance they require or capacity building
measures, on the short or long term, are needed (International Crisis Group 2014).
The security apparatus has significantly reduced institutional capacity; this greatly
hinders the ability to ensure best practices for the critically ill and injured.
12
Denied access
The many locations that the assessment team were denied access is long, and this
will affect the assessment report and will negatively affect the key recommendations
offered as limitations to the study. However, some key locations and agencies that
were not only adamantly opposed to discussion or interview with the assessment
team are the 59th Mobile Field Hospital1 and the State Emergency Service (formerly
the Ministry of Emergencies in Ukraine (absorbed by the Ministry of Defense, not
verified as this department were unwilling to speak over the phone, to allow access to
the office and not willing to receive the assessment team in a formal meeting serially
throughout early August).
This agency is rumored to have two rotary wing aircraft and one fixed wing aircraft
that may be resources and assets that may be utilized for the care of the sick and
injured and are presently grounded for reasons unknown. There is an established
collaborative between this agency and the US Army National Guard of California. This
collaborative has a supposed mobile hospital waiting to be sent to Ukraine for use
immediately. The details of which were not discussed as complete denied access to
this agency. This culture of obstruction has lead to many delays in patient care, access
to needed medicines and possibly access to a free, modern and military grade mobile
hospital.
The culture of disaster agencies to an international standard is to that of prevention,
reduce and mitigate the likelihood and the impact of a disaster; and, in the health
sector, to ensure the functionality of the health facilities and key installations in the
aftermath of a disaster (World Health Organization (WHO) 2012). Disaster
preparedness requires a multidisciplinary, multi-sectorial planning process to
strengthen the capacity and capability of systems, organizations and communities so
that they can better cope with emergencies. These core international standard
components were not assessed as the main emergency and disaster department
would not meet, allow access to their building, answer phone calls or give email
addresses of any members.
The culture of Medicine: Ukraine
Despite rapidly advancing and modernizing medical culture of healthcare staff,
Ukraine still faces many shortcomings with poor organization and management, lack
of adequate resources and a still prevailing paternalistic approach to medicine. This
slightly more conservative approach to medicine seen in some facilities brings with it
a lack of patient confidentiality and patient autonomy. The less than up-to-date
continuing medical education across specialties may also affect best outcomes and is
not yet entirely standardized. The poor resources and deficient management over the
past decade have also left with it a very practical approach to medicine without
concepts such as clinical audit, self-reflective practice and some other hygiene related
practice. Most physicians met and interviewed are highly educated and trained with
fellowships and other exchanges abroad but simply no home country support to better
develop and use the tools and skills learned while away.
The scarcity of adequate medical resources such as funding or basic quality control of
diagnostic equipment, may have developed a culture of distressed medical practice
and inconsistent practice and may lead to less than best medical outcomes. The
reason this culture of practice is commented on is that a cultural block of outsiders
1 After multiple requests, the SBU were willing to offer an official letter to the assessment team were willing to take our lives into
our own hands and sign multiple documents that no security, medical or logistical assistant support would be offered by any
Ukrainian state agency of any kind at any time. These were unacceptable terms to perform an assessment for this agency by the
assessment team.
13
hindered the findings of this assessment and this block may be a barrier to potential
future programming going forward.
Primary assessment lead with indigenous personnel discussing armored ambulance

and MEDEVAC in the red zone
Limitations of Study
This snapshot assessment was only performed and drafted over the course of 12
days. A study with a larger scope for similar area and number of facilities would take 4
6 weeks. The evolution of warfare in the ATO and the nature of war and conflict are
very fluid and dynamic and many events and practices may change without notice
and resource availability dictate what can and cannot be carried out at point of injury
and throughout the medical evacuation chain. The assessments main limitations are
time restraint and access to the ATO and other medical facilities (airfields, fixed and
rotary wing aircraft, etc). These main limitations have been mitigated, if only in part
by excessive interviews and review of other open source information and are cited
and stated as such when done so.
Disclaimer
The views, observations and comments by the primary author do not necessarily
reflect the views or conclusions of the Ukrainian World Congress, Patriot Defense or
any governmental body of Ukraine or any donor, beneficiary or donor government.
This assessment was carried out objectively and with no party affiliation, country
alignment or connection.
14
Main Points of Contact throughout Assessment

Please find below a non-exhaustive list of POCs throughout the study2:
145 Ecans Ave. #207
Toronto, Ontario
+1 416 323-3020
congress@look.ca
Ukraine Office
Muzeynyi Prov. 6
Kyiv, 01001
+380919716363
usuprun@gmail.com
www.patriotdefence.org
Ministry of Defense of Ukraine
Colonel Vitalii Andronatii
Chief Military Medical Directorate
6, Povitrophlotsky Ave.
Kyiv, Ukraine 03168
+380442387484
vandronatiy@mail.ru
US Centers for Disease Control and Prevention (CDC)
4, Sikorsky St., 04122 Kyiv, Ukraine
+380445215093
PodolchakNV@state.gov
International Committee of the Red Cross (ICRC)
Kyiv, Ukraine
Dr. H. Cavogadri
+380674666038
cavogadri@icrc.org
The WHO Representative and Head of Country Office
Dr Dorit Nitzan Kaluski
30, Borychiv Tik Street 04070 - Kyiv, Ukraine
Telephone: +380 44 4258828
Facsimile: +380 44 4258828
whoukr@euro.who.int
World Bank
Paolo Belli, Lead Economist and Sector Leader,
Belarus, Moldova and Ukraine
Human Development Europe and Central Asia
1, Dniprovskiy Uzviz Kuiv 01010, Ukraine
+380444906671 Office
+380501755013, pbelli1@worldbank.org
This list is not exhaustive and many contacts have not be disclosed due to security or other logistical reasons
15
Embassy of Canada in Ukraine

13A Kostelna Street
Kyiv 01901
Tel: 380 (44) 590-3100
Fax: 380 (44) 590-3134
Email: kyiv@international.gc.ca
The Ministry of Foreign Affairs of Russia
32/34 Smolenskaya-Sennaya pl.,
119200, Moscow G-200
dip@mid.ru
+74992444119
International Crisis Group
Avenue Louise 149
1050 Brussels, Belgium
+3225029038
brussels@crisisgroup.org
Delegation of the European Union to Ukraine
101 Volodymyrska St. (see the map)
Kyiv, 01033 Ukraine
Telephone: +380 (44) 390 8010
E-mail: delegation-ukraine@eeas.europa.eu
delegation-ukraine-press@eeas.europa.eu
United States Department of State
U.S. Embassy in Ukraine
4 A.I. Sikorsky St. (formerly Tankova)
04112 Kyiv, Ukraine
+380 044-521-5000
United States Agency for International Development (USAID)
4 Igor Sikorsky Street
Kyiv, Ukraine, 04112
+380-44-521-5000
kyvinfo@usaid.gov
International Medical Corps
Emergency Preparedness and Response
Lunacharsko Street, Suite 425
Kyiv 02002 Ukraine
+380636095165
skhomchencko@internationalmedicalcorps.org
State Emergency Agency Ukraine
55-a Olesya Honchara St.
Boyko Anatoliy Pavlovych
bloshchynska@mns.gov.ua,
Deputy Former Head
Dr. Volansky P. Borisovich
+380672477142
Wings of Phoenix
16
Volunteer Logistics to the ATO

http://www.wings-phoenix.org.ua/en
+380 44 364 50 60
Hospital Facilities Visited

1. Main Military Hospital Kyiv
2. Irpin Military Hospital
3. Kharkiv Military Hospital
4. Izyum Civilian Hospital
5. Dnepropetrovsk Military Hospital
6. Dnepropetrovsk Regional Hospital (Civilian)
7. 61st Military Mobile Hospital
8. Dnepropetrovsk Burns Hospital
9. Vinnistya Military Hospital and Fixed Wing Military Evacuation Aircraft
Schedule and Time Table of Assessment

Dates
July 28th
July 28th
July 29th
July 30th
Location
Main Military
Hospital, Kiev
Irpin Medical
Facility
Kyiv
Kharkiv
Comment
Main tertiary care facility in Ukraine for patients from
the ATO
Rehabilitation Center for the Ukrainian Military
Emergency State Services DENIED access

Regional Military Medical Center supporting the ATO
and mobile field hospital
July 31st
Kharkiv and
Izyum Civilian hospital supports military personnel
Izyum
as proximity facility to current operations
August 1st
Dnepropetrov Main Military Hospital and the 61st Mobile Hospital
sk
August 2nd
Dnepropetrov Military Hospital, Main Civilian Receiving Hospital
sk
and the Burns Center, Medical Evacuation rotary
wing observation
rd
August 3
Kyiv
USAID, ICRC
August 4th
Kyiv
IMC, UNICEF contact, Wings of Phoenix
th
August 5
Kyiv
Canadian Military Attach, ICRC
August 6th
Kyiv
US Embassy: Defense Threat Reduction Office
(DTRA)
August 7th
Kyiv
WHO, DENIED access to state emergency agency
th
August 8
Kyiv
CDC
August 8th Abroad
Assessment writ-up, drafting and desktop review
st
31
September Kyiv
Assessment finalization, follow-up with actors and
st
th
1 12
main stakeholders and press conference preparation
17
Locations visited graphically
The map above shows the major sites visited: Kiev main Military hospital and Irpin
Rehabilitation center, Kharkiv Military hospital, Dnepropetrovsk Military and civilian
hospital and the 61st mobile military hospital.
The basic military organization chart can be found in the below illustration (Buttner
2014). This chart has undergone some revision and the updated chart is not yet
openly available. There are some issues with decision-making and across sectors due
to the legality of the current conflict:
18
Climate and Terrain

Ukraine has a temperate continental and in the south, a Mediterranean climate with
precipitation disproportionately distributed, highest in west and north, lesser in east
and southeast. Winters vary from cool along the Black Sea to cold farther inland;
summers are warm across the greater part of the country and hot in the south and
east (CIA World Factbook 2014). Most of Ukraine consists of fertile plains (steppes)
and plateaus, mountains being found only in the west (the Carpathians), and in the
Crimean Peninsula in the extreme south, there are rolling hills throughout the east and
mountains in the southwest. Ukraine is the second largest country in Europe and holds
a strategic position between east and west.
19
The graphical representation above is of the average rainfall and temperatures,

please note the spike in precipitation is indirectly proportional to temperature twice a
year there are hot and dry summers and cold and very wet or icy winters). Ukraine is
the second largest country in Europe and the climate is not uniform across all of its
territory, this is only an average for illustration. At the writing of this report, the ATO
and area of conflict is consolidated to the East of the country.
Pre-hospital medicine is inherently outdoors. The transport of the sick and injured via
ambulance, helicopter and fixed wing aircraft in inclement weather can lead to patient
care delays, poor medical outcomes and outright increase in morbidity and mortality.
Mitigating these poor outcomes must be a core goal of pre-hospital medicine in
Ukraine with adequate heating systems, safe and protective stations for patient
transfer from mode or transport to further mode of transport and to receiving facility.
A simple and very practical example of this is the use of blankets. The older wool
blanket used in conflicts for the past century is not longer adequate; they can get wet
and become inefficient, carries disease and it is very heavy. The use of a more modern
(mylar, combat/survival) synthetic blanket system that easily secures to patient
transport equipment and is lightweight should be considered. As we will see further in
this report, the mobile field hospitals are completely inadequate and not at all
equipped for operations in cold or wet conditions; these weather changes will render
these facilities completely inoperable for their mission.
Background to Conflict
Demonstrations on Kyivs Independence Square (Maidan Nezalezhnosti) began on
November 21st, 2013 in protest at Presidents Viktor Yanukovychs decision, most likely
made under Russian pressure, not to sign an association agreement with the
European Union (EU) (International Crisis Group 2014). This report will not discuss in
20
entirety the events leading-up to the present conflict in Ukraine, nor will it offer a up
to date threat assessment of the ATO. However, the events that have taken place, the
evolution of warfare in the ATO and nature of conflict do dictate mechanisms of
trauma and consequent management. Due to the very fluid political and military
atmosphere experienced throughout eh East of Ukraine; no in depth background to
the conflict will be discussed.
The Enemy
Ukraine has undergone a social and political revolution with great violence. Presently,
there is an active anti terrorist operation (ATO) with a determined enemy that is
armed with myriad lethal weapons systems and military power. This snapshot
assessment was short and a comprehensive medical audit with quantitative data
collection and process observation will be needed in the future. Russia has undergone
a major military modernization program over the past decade. Many lessons were
learned from the regional conflict in Georgia and elsewhere abroad; Russia represents
a modern regional military power. The hybrid warfare concept being implement
throughout the ATO has kept plausible deniability and responsibility for debauchery at
arms length by Russian ground forces. This half cocked planning and military planning
by Russian forces will remain a commonplace and despites its strategic anonymity,
will inflict death and morbidity to the civilian and military populations for many
months to come.
Recent Events
Despite the legal purgatory that the present conflict in the ATO resides, and despite
the persistent hostile actions by the Russia, the common thread of thought that a
looming humanitarian crisis is budding is clear. At the drafting of this assessment,
conditions in Eastern Ukraine continue to steadily worsen and deteriorate with
violence and insecurity that has put nearly 4 million people at risk and damaged key
civilian infrastructure, including water supplies and medical facilities (United Nations
Security Council 2014). The civilian and military personnel access these basic services
equally.
The evolution of warfare by the terrorists and separatists relies on informal networks
of operatives and fighters and aims to erase the frontier between civil and interstate
conflict (Sherr 2014). Early in August there were other asymmetrical warfare elements
found active and destabilizing. For example, August 5, 2014 the SBU seized five
improvised bombs 7,6 kg total weight, explosive material HMTD for the manufacturing
of detonators, clockwork devices, batteries, a gas gun and covert paraphernalia (SSU
press Center 2014)(please see photos below of these explosive devices and
detonators):
21
These weapons of terror are a clear new threat for not only operations in the ATO, but
also for civilian areas and will cause death and injury with trauma patterns outside the
normal scope of many surgeons.
Furthermore, on August 7th, 2014, a mortar hit a large hospital in the city of Donetsk,
killing at least one patient. A local healthcare worker was able to describe the event,
"there was a sudden explosion, a mortar round flew through the window, all the
equipment was destroyed," at Vishnevskiy Hospital (AP News 2014). This represents a
clear threat and risk for further patient care at this facility and for other healthcare
facilities in the area. Indeed, this causes terror and negatively impacts patient care,
hinders patient care and kills patients while receiving care.
The hybrid warfare practiced by Russian forces currently in Ukraine is more
ambiguous than conventional armed attacks and poses major threats to Ukrainian
civilian and military personnel. The Russian military have crossed the Ukrainian border
at multiple points without resistance and have created significant unrest, are
occupying governmental buildings and have overtaken official military posts and
waypoints incite further violence, give tactical support and are members of rebel
forces and destabilize the entire East of Ukraine. The assessment has not set out to
analyze current Russian and rebel war fighting activity, however the violence caused
in the East by Russian fighters and rebels is directly proportional to the ability of the
Ukrainian military to effectively treat an transport the ill and injured.
Combat Trauma: a very brief overview

Approximately 90% of combat deaths occur on the battlefield before the casualties
reach a medical treatment facility (MTF); many of these deaths cannot be prevented
by medical intervention (i.e. massive head injury and multiple trauma) (Kotwal RS
2011). Those injured that do not die instantly can be effectively treated and
transported by following best practices in Tactical Casualty Combat Care (TCCC) and
Combat Life Saving Care (CLS).
Please reference the ANNEX for the full book of Army Tactical Combat Casualty Care
(TCCC) and other resources, which outline the medical skills, required and algorithms
to be followed when rendering care in the field. As stated in these many handbooks,
deaths in the last decade of modern conflict can be loosely represented as follows in
the table below:
Table. All cause mortality in modern combat (US ARMY 2010)
Penetrating head trauma
31%
Surgically uncorrectable torso
25%
trauma
Potentially surgically correctable
10%
22
trauma
Hemorrhage from extremity wounds
Mutilating blast trauma
Tension pneumothorax
Airway problems
Mostly from infections and
complications of shock
9%
7%
5%
1%
12%
It is estimated that approximately 15% of these casualties that die before reaching a
medical treatment facility can be saved if proper measures are taken such as halting
the catastrophic bleeding (hemorrhage or exsanguination), management of the airway
and sealing open chest injury and relieve tension pneumothorax with needle
decompression and definitive chest tube. The basic concepts offered in the CLS and
TCCC courses are only as good as the medical equipment on hand. Many concepts
such as stopping catastrophic bleeding, airway, primary survey and splinting can be
made with the most basic of equipment. However, the standardized Individual First
Aid Kit (IFAK) (see ANNEX for detailed contents to NATO standard) offer a maximum
benefit at very little cost, minimal training and no burden to troops.
The purpose of the TCCC and CLS courses and ethos is to mitigate death morbidity
due to combat related injuries. These standards are not uniformly being offered for
Ukrainian warfighters at the time of this assessment. A training mission to bring the
Ukrainian forces up to 100% CLS across all uniformed troops should be a priority
(please see key recommendations and conclusions section)
Combat trauma best practices
Approximately 80% of deaths in military operations occur in the first 30 minutes of
injury, when often the only care available comes from self-aid or buddy aid. (Bellamy,
Combat Wounds Ballistics, 1987). The acute need for IFAKs for each uniformed troop
and the appropriate training to be conversant in all of the IFAKs use is mandatory for
self and buddy aid to be affective.
Military operations in the ATO at present involve dispersed, independent units located
far from friendly medical care facilities with long and delayed transport times. The
time, people, and facilities available for delivering advanced trauma care for
casualties are at present severely limited. This situation is particularly serious given
the narrow window of time available to care for serious wounds and injuries before
death. The need for adequate emergency medical transport and critical care transport
is very limited and needs to be expanded to an international standard.
Historically, about 20% of all injured soldiers die in battle, and 90% of those die before
they are treated in a medical facility (Bowen, and Bellamy, Emergency War Surgery,
Combat Casualty Overview, 1998). To salvage any of those casualties, medical care
must be administered immediately, and appropriately. The process of dying after a
traumatic injury has been described as hypovolemic shock from trauma, low blood
volume and end tissue and end organ failures. This uncoupling is the result of blood
loss after injury. In acute trauma and major catastrophic bleeding, tissues and end
organs begin irreversible damage on average within one hour. This golden hour" is
hotly contested in the medical community and is a guideline, not a rigid rule.
However, the golden hour has become an integral part of medical treatment
philosophy, and its concept now extends to many other causes of death. Emergency
physicians have begun using the golden hour phrase with stroke victims, and heart
23
failure as well as trauma highlighting its universal use. The Golden Hour is integral in
pre-hospital medicine to encourage a sense of urgency for immediate medical care,
efficient and focused triage and transport of the ill and injured and appropriate level of
care decisions (surgical, diagnostics needs, medical, etc) as required to ensure best
practice. The Golden Hour concept has undergone changes and criticism since its use;
it should be viewed as a medical opportunity to save life and limb and not be a loaded
term or cause unnecessary risk when transporting or treating a trauma patient.
Roles and Designations of Combat Casualty Care Teams
The NATO standard for combat casualty care is organized into three specific phases
with clear designations of the combat casualty care practitioner. It is necessary to
understand that if military teams are to apply any kind of medical care on the
battlefield a division of levels of care need to be broken down into three phases:
1) Care Under Fire
2) Tactical Field Care
3) Tactical Evacuation Care
These phases of care will require appropriately trained persons to apply the right
techniques at the right time to save and preserve life. The care rendered will need to
be provided to the frontline soldier and war fighter by designated Paramedics,
Doctors, Nursing staff and other professions allied to medicine on the battlefield.
It is therefore necessary to identify the levels of training that are required and those
war fighters who need it. It is a requirement that before medical training for combat
casualty care can be carried out, basic military infantry training and basic group
tactics are practiced at a proficient level and that teams are conversant in weapons
handling and other group tactics; said plainly teams need to be able to shoot, move
and communicate before Combat Life Saver training can be carried out.
Specific roles and definitions
The Combat Lifesaver identifies and fixes catastrophic bleeding, airway problems
penetrating chest trauma and leads casualty evacuation towards definitive care. This
differs from the Combat or Operator Medic who not only fixes catastrophic bleeding,
airway problems, penetrating chest trauma, but also provides continued wound
management, provides continued airway support and stabilization, provides continued
breathing support and stabilization, provides continued circulatory support, stabilizes
peripheral fractures and treats burns, identifies and appropriately treats non trauma
medical emergencies, provides prolonged field care and evacuation towards definitive
care.
An even more advanced level is the Special Forces or Patrol Medic who does all of the
above, as well as, identifies and treats non trauma medical emergencies, provides
prolonged field care and evacuation towards definitive care and finally applies all of
the above within the SF Operators area of operations, (Sea, Land, Air). The definitive
TCCC operator is the Combat / Tactical Physician / Paramedic. This role is defined as
providing all discussed above, as well as, provides basic surgical support, identifies
and treats illness in line with general medicine codes of practice and refers for
ongoing treatment and care, manages a field aid station, provides guidance and
support in field hospital operations and hygiene practice, is competent in the practice
24
of pre-hospital trauma life support to the ATLS/ITLS/PHTLS standards and finally is

competent in the practice of advanced cardiac life support (ACLS).
Operational Roles for these designations are clearly defined as follows:
Combat Lifesaver
All armed service personnel should receive basic Combat Lifesaver (CLS)
training.
Combat / Operator Medic
Select personnel at unit / section level should be selected as Combat / Operator
Medics. 1 medic per 12 war fighters / troops should receive this training.
Special Forces / Patrol Medic
Select persons within a SF team should be selected as SF Medic. One per 6
troops / war fighters should receive this training. Select persons within an
infantry unit should be selected as Patrol Medic. One per 20 should receive this
training with one senior Medic per 40 persons.
Combat / Tactical Physician / Paramedic
Physicians working within a military environment should all undergo this level of
training, especially where they are required to manage a field aid station and
provide evacuation care in a ground vehicle or fixed, rotary wing aircraft. Two (2)
Physicians would normally cover 300 soldiers.
Emergency Ultrasound the eFAST
Ultrasound has emerged as a sensitive and reliable tool to evaluate patients
presenting to the emergency casualty area with acute and sub-acute thoracicabdominal trauma and hypotension (Soyuncu S. 2007) (Chason 2008). Focused
bedside ultrasound can accurately detect fluid in the peritoneal and pleural cavities
and air in the pleural cavity, and it is more reliable than physical examination alone
(Rothlin M.A. 1993). Furthermore, use of bedside ultrasound in thoracic-abdominal
trauma expedites time to definitive care; because it can help determine whether an
emergent intervention such as chest tube thoracotomy or trauma consultation and
surgery are required (Melniker L.A. 2006). eFAST is an evolving exam and a negative
result does not mean the mechanisms of injury and injury suffered are static.
Ultrasound use in the field has been described in Germany, France, Italy and the USA
(Walcher F 2008). In the USA, it is common for non-physician EMS crews to focus on
rapid transport of patients to emergency departments. In other areas, providers spend
more time on scene evaluating and managing patients, and physicians are often part
of the field team. Thus, the indications for and utility of point-of-care ultrasound may
differ based on the practice environment of a particular clinician.
In Germany, the use of ultrasound in the field has focused on the FAST exam and
cardiac sonography for non-traumatic patients. The German Air Rescue Organization
(Deutsche Rettungsflugwacht) as well as several ground-based ambulance services (in
Darmstadt and Frankfurt/Main) have incorporated ultrasound into their field
management algorithms since 20022003. Emergency physicians and paramedics
comprise the crews in these centers (Walcher F 2008). The use of field ultrasound to
25
assist with transport decisions when limited air assets are available has the potential
to be a force multiplier in the ATO. Becoming fluent with the use of and assisted
decision making for clinicians with bedside ultrasound is an international standard
that can be instituted by all physicians at mobile hospitals in the ATO.
A negative eFAST does not exclude entirely the presence of thoracic-abdominal injury,
free fluid in the abdomen or any significant injury. Small amounts of free fluid and
small pneumothoraxes may not be visible on an initial eFAST. Patients with stable vital
signs and a concerning history should be observed for at least 4 hours and have the
eFAST repeated; and repeated if patient signs and symptoms deteriorate, change or
become unstable. The need for physician led assessment, re-assessment and triage in
a fluid state is of utmost importance. During the assessment, some injuries were
missed, the severities of injuries given by the sending physician were taken for
granted and morbidity may have ben affected. Repeat eFAST should be performed
sooner if a patient's clinical picture is deteriorating and vital signs become unstable.
Being able to provide a basic FAST or eFAST exam is now the standard of care in
trauma and it offers great decision making capability for surgical evacuation when
resources are limited.
Mechanisms of Trauma: the ATO in action

The weapons used throughout the ATO and in covert activities are diverse and cause
death and injury. However, trauma observed in the short 12-day assessment did see a
common thread of injury patterns from the GRAD rocket system and AK-47 7.62
caliber weapons. Anecdotally, most trauma surgeons rank injuries of patients who
have survived trauma to that of peripheral, chest and abdominal injuries with
fragmentation patterns consistent with these weapons systems.
There were also speculations of white phosphorous and other chemical agents being
used in the conflict, which could not be verified during the time of this assessment.
These weapon systems are debilitating and lethal. This section aims to simply review
and define what some of these agents are and how they relate to emergency
management of soldiers in the ATO. The core concepts of CLS and TCCC are based on
the mechanism of injury and dictate the index of suspicion and treatment and
transport priorities.
The descriptions below are not an expert weapons report of the armament seen
throughout the ATO, however, a basic review of the some of the systems being
implemented reflects the impact on injuries. The BM-21 launch vehicle is
a Soviet truck-mounted 122 mm multiple rocket launcher and a M-21OF rocket were
developed in the early 1960s (Foss 2013). The complete system is more commonly
known as a Grad multiple rocket launcher system that hails down multiple
fragmentation high explosives to its target area.
26
The above photo is a GRAD weapons system and truck at a military parade in Yekaterinburg, 9 May 2009 (Wikipedia 2014) and
the photo to the right is from a recent attack on a warehouse in the ATO with the Grad system.
The photo above highlights injury patterns and mortality associated with the GRAD weapons system as seen in the ATO by civilian
workers at a warehouse in Dobropillia, Ukraine in mid June 2014 (Censor.NET 2014). The injury pattern is chest and abdominal
fragmentation injuries with exsanguination and death.
AK-47 and small arms

The AK-47 and its descendants have defined and exacerbated half a century of
guerrilla conflict, terrorism, and crime; it is the most abundant firearm in the world,
with as many as 100 million Kalashnikovs in circulation, 10 times more than any other
rifle (Homans 2010). This weapon is widely available throughout the ATO and does not
distinguish between combatant and civilian.
The AK fires the 7.6239mm cartridge with a muzzle velocity of 715 m/s (2,350 ft/s);
the cartridge weight is 16.3 g (0.6 oz), the projectile weight is 7.9 g (122 gr)
(Rosoboronexport, OCLC 2003). The AK has excellent penetration when shooting
27
through heavy foliage, walls or a common vehicle's metal body and into an opponent
attempting to use these elements as cover. The 7.62x39mm M43 projectile does not
generally fragment when striking an opponent and has an unusual tendency to remain
intact even after making contact with bone (ML. 1988). The 7.62x39mm round
produces significant wounding in cases where the bullet tumbles in tissue, (Bellamy
RF 1990) but produces relatively isolated wounds in cases where the bullet exits
before beginning to yaw (FACKLER, et al. 1984) (Fackler ML 1985). In sum, this
weapon and round cause significant tissue damage and morbidity and mortality. The
illustrations below show the ballistic trauma to tissues.
The image above illustrates the yaw and components or the ballistics with the AK-47 and how it causes significant tissue and
organ damage.
White Prosperous (WP)

Evidence that white phosphorous is being used in the ATO has not been objectively
verified as of the drafting of this assessment report. However, there are multiple
accounts and reports by the military and civilians that white phosphorous is being
used in the ATO at different modalities.
White phosphorus is used in smoke, tracer, illumination and incendiary munitions
(Koch 2008). As an incendiary weapon, white phosphorus burns fiercely and can ignite
cloth, fuel, ammunition and other combustibles. In addition to its offensive
capabilities, white phosphorus is also a highly efficient smoke-producing agent,
burning quickly and producing an instant blanket of smoke to provide temporary cover
and to assist with breaking contact (TR 1983). As a result, smoke-producing white
28
phosphorus munitions are very common, particularly as smoke grenades for infantry,
loaded in grenade launchers on tanks and other armored vehicles, or as part of the
ammunition allotment for artillery or mortars (Wikipedia 2014). These create smoke
screens to mask movement, position, some weapons targeting systems, or the origin
of fire from the enemy.
Injury patterns
White phosphorus can cause injuries and death in three ways: by burning deep into
tissue, by being inhaled as a smoke, and by being ingested. Extensive exposure by
burning and ingestion is fatal. Particles of WP cast off by a WP weapon's detonation
produce partial and full thickness burns (Barillo, et al. 2005). One reason why this
occurs is the tendency of the element to stick to the skin and keep burning and
oxidizing with access to open air. Phosphorus burns carry a greater risk of mortality
than other forms of burns due to the absorption of phosphorus into the body through
the burned area, resulting in liver, heart and kidney damage, and in some
cases multiple organ failure (Skaik S 2010). These weapons are particularly dangerous
to exposed people because white phosphorus continues to burn unless deprived of
oxygen or until it is completely consumed.
Smoke inhalation
Burning white phosphorus produces a hot, dense, white smoke. Exposure to heavy
smoke concentrations of any kind for an extended period (particularly if near the
source of emission) has the potential to cause illness and death. White phosphorus
smoke irritates the eyes and respiratory tract in moderate concentrations, while
higher concentrations can produce severe burns (RD 1998).
Fume Inhalation
Long-term inhalation of derivative fumes cases a painful jaw claudication and death.
The mechanism for necrosis is clot formation leading to bone ischemia or infarction,
leading to the putrid rotting of the bone of the lower jaw. First aid for white
phosphorous burns is to remove the source and remove oxygen with wet dressings.
Definitive care is to surgical remove all particles of WP. Airway complications are
treated empirically and may involve intubation and ICU care.
Infectious disease and illness in conflicts: a very short review of acute
threats
Conflict and war fighting activities are inherently dangerous and expose people to
increased risk of trauma and illness. The breakdown of health, hygiene, sanitation and
public health infrastructure in war and war fighting activities leads to a decay in
health security for civilian and military populations. As seen in recent urban and mixed
rural conflicts in Iraq, Syria and Africa, infectious disease buffer and prevention
systems such as vaccine programs and basic services such as potable water,
sanitation, refrigeration and cold chain management, and many others, are strained
or no longer existent. This absence of basic services and public health infrastructure
leads to potential risk of infectious disease to these vulnerable populations.
At present in the ATO and surrounding areas, WHO are gathering data on the health
needs, gaps and responses and response capability to catastrophe. These include
tetanus prevention and treatment access, polio exposure, mental health needs of
vulnerable groups and Internally Displaced Peoples (IDPs) (World Health Organization
August 2014). These weekly reports from the WHO throughout July and August
highlight the great stress on the emergency and primary health care services in
conflict areas described as exhausted with inconsistent electricity and water supply
within the area, as well as facing extreme lack of pharmaceuticals, medical
29
consumables, human resources and logistics constrain (World Health Organization

August 2014)s.
For example, Emergency health care in Donetsk is at breaking point and collapse with
these deficiencies in adequate resources and compiled strain, especially on prehospital services. This is seen with inadequate fuel for ambulances, poor cold chain
management for pharmaceuticals and vaccines and a dearth of medical consumables
and multiple other pharmaceuticals. These are presently no access to antivenin for
the poisonous snakes or spiders within the region. These is sufficient evidence and
concern within the public health community of an impending outbreak of polio,
tetanus related illness due to these many stressors found within conflict.
Stress
Anecdotally, all physicians interviewed and asked to rank the order of illness and
injury they see on average in the ATO and patients departing the ATO commented on
reactive psychiatric conditions, most notably acute stress reactions from traumatic
stress. The treatment and prevention of traumatic stress for soldiers and support staff
is an integral component of going to war pre crisis, post crisis and post conflict
stages. Both civilian and combatant populations are at risk of stress, stress reactions
and posttraumatic stress disorder (PTSD) (Pietrzak, et al. 2012).
This assessment did not assess the risk or factors associated with stress and combat
related illness related for war fighters or civilians. The adequate preparation,
prevention and treatment associated with this spectrum of disorders should be
reviewed by the Ministry of Health and Ministry of Defense to ensure best outcomes
and avoid a potential community mental health crisis. Returning soldiers, volunteers
and war fighters will exhibit elements of stress, posttraumatic stress and other
psychiatric disorders returning from the battlefield regardless of location or war
fighting activity involved in. Society, the Ministry of Defense and multiple
governmental agencies need to encourage training and awareness programs related
to this spectrum of disorders.
Communications an overview
Communications in Ukraine are mandated and controlled by the Ministry of
Infrastructure in Ukraine and the State Special Communications Service of Ukraine.
Mobile phones are widely used throughout Ukraine and many service providers are in
part Russian owned and or operated (please see table below of mobile carriers in
Ukraine as of 2008):
Table 2. Mobile Cell Networks in Ukraine (CIA World Factbook 2014)
Ran Operator
Technolo Subscribe Ownership
k
gy
rs
(in
millions)
1
Kyivstar
GSM
23
Telenor (56.51%), Alfa Group (43.49%)
2
MTS
GSM, CD 19
MTS (100%)
MA
3
life:)
GSM
9
Turkcell (54.2%), SCM Holdings (45.8%)
4
Beeline
GSM
2
VimpelCom
5
Utel
UMTS
0.3
Ukrtelecom
6
PEOPLEnet
CDMA
0.3
Telesystems of Ukraine
7
Intertelecom CDMA
0.3
Intertelecom company
30
8
9
10
CDMA
Ukraine
Velton
Golden
Telecom
CDMA
0.3
CDMA
GSM
?
0.05
International Telecommunication
Company (ITC)
Velton Telecom
Golden Telecom Inc. (GLDN)
The standard for medical evacuation and medical communication between ranks,
facilities, ambulances and rotary and fixed wing medical aircraft is encrypted radio
(base mount, repeater and mobile handheld). The use of satellite phones, mobile and
landline phones and email or text message are all secondary or tertiary use and have
no operational security or patient confidentiality. The operational security of the use of
mobile phones for any patient movement, or other military operation should be
reconsidered.
Medical Evacuation
Medical evacuation (MEDEVAC) is the movement of casualties by medical ground or
medical air ambulances to a medical treatment facility. Although many military staff
and soldiers are not a medical professional, they may be required to initiate a medical
evacuation request and do so in a uniform, standardized and efficient manner. A
MEDEVAC is when medical personnel transport a casualty; CASEVAC is when a combat
lifesaver (CLS) may use a non-medically equipped vehicle to transport a patient.
MEDEVACs must use encrypted radio at times of war to ensure operational security;
and at night may have to use light discipline to ensure security. Radio silence and no
names, names of locations should be spoken over the radio net. The multiple facets of
security operations in a MEDEVAC will only be mentioned cursorily in this report. A
MEDEVAC 9-line report must be made with request and be communicated to a
coordinating center.
The information contained in the MEDEVAC helps medical units to determine the
correct priority for committing evacuation assets. This helps to control the evacuation
flow so that medical resources are not overly strained. Accurate information on the 9line request will help to ensure that casualties receive rapid evacuation. Proper
casualty classification is needed to ensure that casualties are evacuated according to
their needs. This assessment did not employ NATO standards of evaluation for medical
evacuation in the ATO. However, there are NATO medical evaluation and operations
documents in the ANNEX for review and reference.
31

An example of patient evacuation coordination center with joint operations.
Rotary wing
The photo above was taken in April and open source. Ukrainian soldiers are seen near a MI-8 military helicopter and armored
personnel carrier at a checkpoint near the town of Izium in Eastern Ukraine, April 15, 2014 (Reuters / Dmitry Madorsky. 2014).
This medical evacuation helicopter was subsequently shot down with surface to air weapon systems before the assessment was
carried out.
The use of rotary wing aircraft for medical evacuation has developed considerably
throughout warfare. It remains the most agile means of medical evacuation across
difficult terrain, distances and battlefield conditions.
The Ukrainian Experience
Ukraine is at war with a poorly kept, poorly funded and gutted military apparatus. At
the time of the assessment drafting, multiple medical evacuation rotary wing aircraft
had been taken down with antiaircraft ordinance. Due to security concerns and access
control, the assessment team were not allowed to film or photograph the process of
medical evacuation receipt from the ATO with rotatory wing aircraft to a regional
airfield. This is in attempt to objectively describe the one evacuation process
witnessed on August 2nd in Dnepropetrovsk at approximately 11:15 am on the main
flight line near the
A military MI8 circa 1980s arrived form the northeast at standard altitude and
approach. It taxied on the flight line for approximately 7 to 10 minutes towards
awaiting 8 civilian ambulances adjacent to the tent hospital at the flight line. The
aircraft appeared poorly maintenance with evidence of oil and fire damage to the tail
boom. The ambulances awaiting patients were lead by the regional medical director of
military medical evacuation in Dnepropetrovsk. Each ambulance was kitted out
slightly differently with variants in the number of patients and severity able to
transport. Each ambulance had a driver, an assistant or nurse, a medical professional
(doctor or paramedic). Most doctors were wearing scrubs and barefoot with sandals,
some had personal protective equipment jackets. All ambulance cots were not
extended and upright but in the resting and collapsed position on the flight line. All
32
engine ambulances were turned off. The ambulances were waiting for patient
exchange in the open. The weather was warm, dry and clear.
There was a security delay to sweep the aircraft for ordinance or other security
threats or hazards. This Mi-8 is a transport and non-medical evacuation equipped
aircraft. There is one small port side door access and small step. There is no starboard
or aft entrance/egress points. The assessment team was not granted access to the
aircraft and was told that there were no medical equipment or apparatus on the
aircraft. The aircraft powered down. An aircraft support team stood-by, the medical
director entered the aircraft and triaged the wounded. There were 14 patients onboard, 2 deaths upon arrival. The least severe patients were taken off first, were told
for ease of access. Some of these patients were ambulatory. The most severe were
taken off last via stretcher.
The patients were sorted by the medical director for dispersion to the two main
receiving hospitals in Dnepropetrovsk; the most severe to the city civilian regional
hospital and the less sever to the military hospital. The transport time is roughly 30
and 35 minutes respectively demanding on traffic. All patients were asked to sit on
the ambulance trolley/cot or asked to sit in the ambulance bench or seats for those
that took more than one patient.
This exchange took place in front of all staff returning to the ATO (approximately 12
other soldiers and military staff standing by to board. This process is not good for
morale as dead and dying soldiers coming out of the ATO in directly in front of the
troops headed into theatre. There needs to be NATO standardized rotatory winged
aircraft for the purpose of medical evacuation wit full critical care equipment, medical
staff and rescue equipment and access to the aircraft (multiple access point to fit
appropriate trolleys and stretchers). The use of appropriate personal protective
equipment (PPE) by medical staff receiving patients and all aircraft crew is mandatory.
Radio communication between medical staff on the ground and in the aircraft is also
mandatory. This needs to be portable and mobile and easily used hands-free and
across specialties and disciplines. This will aid in patient care and outcomes. All efforts
need to be made to have patient exchange as close to the receiving hospital as
possible to ensure minimal time loss and mitigate morbidity and mortality.
33
The photo above illustrates the flight line for a receiving medical team of rotary winged aircraft. Notice the lack of PPE by flight
line crew and medical staff.
Fixed wing
Lviv,&
Vinnystya,&
Odessa&
34
!!
=!!MI8!helicopter!used!for!medical!evacuation!!!
! =!Static!Hospital!!
! !
! !
=!Doctor,!Nurse!and!ambulance!!
=!Mobile!Field!Hospital!!
The diagram above is an attempt to illustrate the basic schematic of how medical transport takes place when assessed from point
of injury to tertiary care facility.
Vinnytsia
Deputy Chief Colonel Olexandr Stoliarenko
+380 67 430 2137
stolyarenko@i.ua
Ministry of Defense
Military Medical Center of Central Region (Vinnytsia)
Lead Medical Flight Officer, Anesthesia
Vinnitsa is a full service 650-bed hospital and is on average well maintained and
equipped to the standards of practice available within country. Patients from the ATO
are airlifted via primary transport to a mobile hospital, via ground or rotary wing
transport to mainly Dnepropetrovsk or Kharkiv. From these medical centers, upon
requirement of further transport or specialty care, ground transport takes the patient
either to the civilian Dnepropetrovsk or military flight line in Kharkiv for coordinated
transport via fixed this fixed wing military transport. As noted earlier, the
Dnepropetrovsk civilian/military flight line and airport are roughly 35 minutes on a
weekend day in good weather from the civilian hospital and roughly 30 minutes form
the military hospital. For Kharkiv, the civilian airport is about 25 to 30 minutes away
on a weekday in good weather from the military hospital. The assessment team was
serially barred access to the military flight line and this element of the evacuation
chain was not assessed.
The Vinnitsa hospital has no heliport. The two best hospitals (per staff) for treatment
of all types of patients from the ATO are Vinnitsa or Kyiv both able to accept polytrauma and offering tertiary care. Eye injuries are transported to Odessa Military
Hospital when feasible. Patients from the ATO are transported to either Kharkiv or
Dnepropetrovsk. To review and clarify, from there they are then flown by long range
aircraft to hospitals in Odesa, Vinnitsa, Kyiv or Lviv. As stated earlier, an additional
hospital was available in Crimea but was lost to the Russian who now occupy the
facility.
35
The aircraft specifications as stated by the flight crew are as follows:

Aircraft: Anton 26 - (1)
Three critical and ten ambulatory patients can be transported
They fly with 10 people 6 nurses and 4 doctors.
Second larger aircraft not in use at time of assessment
Equipment
Ventilation, EKG, infusion (critical care transport) Jump Bags with drug kit
Two doctors have taken course in USA
According to Ukrainian law only an anesthesiologist can intubate a patient. So all
flights/mobile hospitals must have an anesthesiologist and all crew must check out all
controlled substances before lift-off .
Helicopters used Mi8
Equipment for helicopter - jump bags from Mobile Field Hospital
Available 24/7
Helicopter evacuation done by mobile hospital staff. 350 KM range. Non-dedicated
aircraft
Two anesthesiologists and two assistances (nurses)
Met with the chief doctor from one of two field hospitals in the ATO.
, 59 0676039916
email: y.podolian@mail.ru
Two Field hospitals (he is responsible for one) in Lugansk
Most injuries seen: Shrapnel extremity
Needs medic bags, IFAK, vent, defib, monitors, portable x-ray, Good supply of most
disposables.
30-60 minutes on average to get to mobile
Immediate transport when required, non-medical military aircraft on stand-by
Treatment as of Aug 5th, 2014 450 air-evac, 2000 by ambulance/ground transport
200+ operations
50 persons on average on staff, hope to increase to 100 in the near future.
36
Portable medical equipment for the fixed wing aircraft.
Jump bag for the fixed wing aircraft, Ambu bag and BP cuff and assorted medical equipment and suitcases.
37
Airway bag for the fixed wing aircraft.
Drug bag for the fixed wing aircraft: note that when on-call there is a lengthy sign-out process to receive medications
appropriately to respond to emergencies. It may be more streamlined if this drug bag was checked-out and zip tied or locked
complete to ensure fast response to medical emergency.
Dr. Anatoly Andronatti Medical Director Medical

Evacuation
Proct.gvkg@mail.ru
+380445218450
+380503347367
A short interview was offered with Dr. Andronati, the medical director and head of
operations for all medical evacuations out of the ATO. Much of the basis for medical
evacuation across sections as described was gleaned from this interview and is
located many sections of this report. Battlefield medicine is carried out as each
38
medical professional are trained to do. His headquarters leads on the coordination and
communication of medical evacuation needs throughout the ATO. Communication is
difficult, mobile phones are used and there are at present no access to encrypted
radio communications to reply patient data, needs and required resources.
At the time of the assessment, Dr. Andronatii has assisted in roughly all medical
evacuations, 300 to date he had been directed involved in. There are Brigade level
clinics which may or may not function well and have adequate resources, with medics
and doctors functioning at various levels of medical practice. A review was offered
about the mobile hospital facilities and where they sit within the medical evacuation
system. Basic surgical capabilities are carried out at the mobile hospitals to the level
of physicians offered. Comment on the aircraft and its capability was also made, the
constant use and need for more were also commented on. The use of and quantity,
albeit dwindling, of usable rotary winged aircraft for medical evacuation were
commented on. At the time there were more aircraft and one was built for purpose.
By the time of the drafting of this report, multiple war fighting activities have
deteriorated the number of helicopters in operation. At the time, there were no night
flights; approximately 25 patients per rotary aircraft were being transported per flight
with no or grossly inadequate medical transport critical care resources. The number of
ambulances being used for transport of the ill and injured ranges from 30 to 50; these
transporting patients from the battlefield to mobile hospitals and other medical assets
for care. There were no armored ambulance assets in use at the drafting of this report
and two rumored armored APCs en route to the ATO. APCs make very difficult
ambulances and the need for larger armored ambulances with offensive capabilities
will assist sufficiently with transport of the ill and injured.
Mobile medical assets were described: Mobile 59th, mobile 61st, Shastiya, Izum,
Dnepropetrovsk and Kharkiv. The map describes what Dr. Andronatii has explained
and what was gleaned from the assessment in the field. Highlighted needs for the
mobile hospitals are a complete upgrade. Lighting, surgical capabilities, x-ray
equipment, labs, diagnostics, food and hygiene and all basic life support facilities of
the mobile hospitals are in question. In order to ensure best practices, these mobile
hospitals must be completely demobilized and modernized.
In sum, the medical evacuation process is not said to be to a NATO standard but the
goal and guidelines of such were of utmost importance it future design. The process of
medical evacuation is very centralized at present for patients moving out of the ATO
and to request critical care transport out of the ATO. It may benefit having a command
center with standing orders and protocols decentralized to allow faster decisionmaking capabilities for the ill and injured to get out of the ATO and to request
transport. Such a central command center would be closer to the ATO and have
encrypted communication capability.
Site Visits
Main Military Hospital Kyiv
36UUA 24851 89244
Description:
This 1000+ bed hospital is situated in Kyiv, just outside the city center. There are 12
surgical theatres able but not presently operating 24 hours a day. There are
approximately 2200 total staff, 200 military doctors and 400 other state sourced
physicians working in and throughout the facility. There is one 64 slice CT machine on
site and 2 MRIs, one 1.5 tesla and one 0.5 tesla. At the time of the assessment, there
39
were approximately 825 patients on campus, 130 of which were from the ATO directly
(illness and injury related). The labs here have full biochemistry, hematology,
bacteriology and virology capabilities. For any detailed tests required, city center Kyiv
has private lab facilities (not assessed) for confirmatory test infectious disease, beta
naturitic peptide and some others. There is no helipad on site, however there are
many areas where a helicopter MI8 or other rotary wing aircraft may be able to land.
The blood bank on site is to an international standard and is adequate for its
operation. However, it is too far from the ATO to have its supply service direct to the
ATO.
Patients can be air evacuated from elsewhere throughout the country to the military
airport in Kyiv or to the civilian and then ground transported to this facility. There are
two ambulances currently based at this facility, with multiple reserves offered by the
city in the event of a mass casualty incident (this system component was not tested).
The system is set in place such that patient requiring advanced surgical and other
medical interventions not capable in Kharkiv or Dnepropetrovsk can be evacuated to
Kyiv Main Military Hospital and possibly onwards to Irpin for further rehabilitation if so
required. There are surgical specialists at Irpin.
Strength:
This hospital is centrally located in the Kyiv. Its access to some of the nations best
specialist, surgical and other specialists is ideal. It is the largest military medical asset
and is centrally located.
Vulnerability and Risk:
This facility has no means of accepting a patient via rotary wing aircraft at present,
has a relatively lenient security posture at time of war and is an open campus in a
country that has significant subzero temperatures for over 35% of the year.
Conclusion:
This facility can see about the logistics of creating a helipad to receive patients at the
ambulance yard, can see about shuttling consistently surgical specialists to the ATO
and can still serve as the main base of operations for medical evacuation coordination
with advanced communications to the ATO and regional medical facilities (not mobile
phones). Its strategic location to the capital is helpful as a support and nerve center
for the current ATO.
Irpin Military Hospital and Rehabilitation Center
36UUB 06552 02694
Description:
This large sprawling campus is roughly 45 minutes to an hour outside of Kyiv and
serves as a remote medical center for rehabilitation medicine and other elective
medical procedures for the military. It has 280 beds, sees roughly 9000 patients per
year was actively treating roughly 50 patients from the ATO at the time of
assessment; 200 in total from the start of major hostilities. Anecdotally, a majority of
patients from the ATO suffered gunshot wounds of varying caliber and blunt and
penetrating trauma associated with the GRAD and artillary weapons systems. It is in
in a discrete location set in the forest with minimal signage. It should be notes that
the main neurological and larger rehabilitation facility for the military is located in
Crimea. This center boasts a very large campus with multiple rehabilitation facilities
that is not longer available and was not assessed during this assessment due to
access issues. Surgical capabilities include both trauma and laparoscopic and there is
40
no CT or MRI but basic ultrasound and radiology is on site. This center would serve as
a major receiving facility for those patients suffering form posttraumatic stress
disorder (PTSD). PTSD and other mental health and a myriad of neurological which will
have an increase in incidence with the onset of operations and this facility is ill
prepared for a potential boost in patient volume.
The most glaring issue Irpin faces at present is the increase in multiple drug resistant
organisms from penetrating trauma requiring vacuum therapy. Second to this, the
amount of incoming barotrauma with eardrums and other ENT related illness was on
the rise. There is full audiometry on site for treatment and rehabilitation, to include
water, light and radiotherapy.
Strength:
This facility is in a remote but still easily accessible location to Kyiv. Specialists can
shuttle back and fourth to perform ongoing detailed follow-up surgery, there is a
sprawling campus for many patients returning from the ATO who may need
rehabilitation and surgical needs.
It is on Google maps and may still be a military target. At present, it is located far
from the ATO and has limited tertiary care facilities and diagnostics. If there were to
be a significant increase in war fighting activities, it is not clear if Irpin could handle a
boost of 15 to 20% increase in patient volume with staffing and its facility.
Conclusion:
Irpin is a great rehabilitation center and is located close to Kyiv. It can be used for
rehabilitation and some minor surgical needs.
Kharkiv
Description:
The military Hospital is a large campus and multiple surgical and diagnostic
capabilities and represents the major tertiary and receiving hospital facility
throughout the region (please see map on following pages). This is not only the core
military resource hospital for the region, it also in charge of resupply medical goods
throughout the region. Its supports 5 major hubs: Kharkiv, Voltam, Chernisia, Cherne
Raj and Desna. Kharkiv Regional boasts general, trauma, neuro, thoracic, abdominal,
urology and hand surgical capability. There are approximately 150 doctors on site, 475
beds, one 16-slice CT, no MRI, x-ray (not for in-theatre or surgical use), ultrasound,
labs to include biochemistry, immunology and hematology. It was estimated by the
medical director that roughly 60% of patients coming out of the ATO are sent to this
facility.
The estimated time from point of injury to being received at Kharkiv was 5 to 12
hours. The two patients interviewed stated that due to delays, they had made it to the
facility in 24 and 10 hours respectively, both suffered peripheral trauma from sniper
and GRAD rocket attacks and both required external fixation that could have been
internal if a c-arm had been available. Trauma surgeons interviewed reported issues
with vascular repair deficiencies and the use of tourniquets, some older models.
Surgeons are seeing multiple hemostatic agents used in the field, some without need
for minor bleeding. There was no case at the time of the assessment of loss of limb
due to unnecessary tourniquet use. A majority of periphery trauma were descried at
penetrating injuries from blasts and small arms fire; mostly open tibia / fibula, femur
41
and radius/ulnar trauma all requiring external fixation due to no c-arm capabilities.
The trauma surgeon interviewed stated cephalosporin and tetracycline covered most
infections they encountered.
At the internal medicine department, the main concern for morbidity of disease was
from cellulitis, necrotic wounds and abdominal infections leading to sepsis. He has
seen a 90% infection rate with limb trauma, mostly staph and strep infections
susceptible to cephalosporin. Multiple consults to psychiatry had been made for acute
stress of troops suffering wounds and treatment, no suicides to date had been
associated with treatment at this facility.
Anecdotally, trauma is the overwhelming receipt of patients from the ATO, penetrating
and blast. For Non-communicable disease related illness, pneumonia, myocarditis and
other respiratory related illness are of note. The use of ground transport from the
military flight line approximately 30 minutes away was not observed, access was
denied. The two ambulances used and base out of this facility are grossly dated and
underequipped. One ambulance lacks heat or any medical supply of any kind. One
German model is from 1983 and one Ford is from 1993, both have adequate diesel for
transport.
Strength:
The geographical location of this facility and campus size make it a potential true
power to serve as a combat support hospital for the ATO.
The expansive medical facility is in need of upgrades. It as designed for peacetime
medical operations and is ill equipped to act as a field support or combat support
hospital. An increase in patient volume requiring ICU for example will exceed this
facilities capability rapidly. There are some surgical soft and hard goods such as c-arm
x-ray that limit surgical capabilities and limit best medical outcomes. These include
adequate lighting, c-arm radiology, respiratory equipment and anesthesia equipment
surgical tables and secondary lighting. Endoscopy is functional but with limited use.
The ground ambulances used for medical transport are old and need to be updated
and modernized.
Conclusion:
If this facility is to serve as a true support facility and not require all patients to
undergo further transport to Kyiv or elsewhere, significant upgrades and investment
into medical hard and soft goods, as well as, building and resources.
42
More
The above map highlights the Regional Hub Kharkiv and its recipient medical centers, notice Izium, Lugansk and Donetsk in the
southeast of the map
The map above is the route traversed via ground ambulance to and from Kharkiv to Izyum.
The route takes approximately
to
20142Google
2.5 hours and is on a terrible road with multiple holes, poor lighting, dangerous conditions and staffed checkpoints. At time of the
assessment a patient was being transported with multiple fractures and an external fixation device in situ, the pain was
unbearable for 2 solid hours.
http://www.movescount.com/moves/move37260920
2/4
43
Kharkiv Airport Clinic (Civilian)

Description:
This small outpatient clinic is located about 12 minutes drive from the Kharkiv facility.
The military flight is much further away and has no treatment capability on site it
should be noted that the assessment team were barred access to the military facility
and all details were given secondhand. There is one physician and one nurse here
available 24 hours a day. The clinic has access to both open and the controlled airport
areas.
Strength:
Proximity to Kharkiv medical facility, 24-hour operation and access to basic services
associated with an airport. There is a devoted Mercedes ambulance on site, multiple
AEDs, basic trauma supplies and mass casualty equipment for up 100 patients.
This is located at a civilian location and large movements of military assets or patients
may be difficult when applying IATA standards.
Conclusion:
Until the military flight line has adequate resources, it may benefit patients to use this
facility and flight line in the transport and triage and treatment if the ill and injured
coming out of the ATO.
Izyum
Dr. Oleg Shikoksy
+380502741721
tzarmoleg@windowslive.com
Description:
This smaller medical facility is situated on a campus with multiple constructions
projects at multiple stages, none of which are complete. Due to the regional location
to both Donetsk and Lugansk, Izyum serves as a de facto receiving facility for many
war fighters, volunteer and enlisted. There are approximately 180 doctors working
out of this facility, 20 surgeons, 2 surgical theatres available but not operational 24hours a day and roughly 50 patients seen per day with 40 in patient beds and 8 ICU
beds. On average, 400 ATO patients had been seen here directly, however the
medical director stated that roughly 12 to 20 new patients were being seen more than
usual per day in late July and early August. There is no CT, no MRI, 1 stationary x-ray,
5 modular and mobile ones, 3 10 year old ultrasound machines and basic labs offering
biochemistry, hematology, immunology and some bacteriology.
Strength:
The geographical location on top of the ATO is the strength of this facility.
This is a very small, low resourced and forgotten medical facility with very limited
resource. It is not strategically defended and despite central ATO command being
within its area, there is little to no military presence.
Conclusion:
This medical facility requires further upgrades, resource investment and staffing. This
is the de facto receiving facility for many casualties coming in from the ATO.
44
Dnepropetrovsk
Main Military Hospital in Dnepropetrovsk
Description:
There is much resistance to the assessment team and to outside support found at this
facility. The state of the infrastructure of this hospital is very dire and in some
instances no longer functional or operational. There are many surgical specialties from
the military that consult and visit this hospital from Kyiv but lack the shear surgical
equipment such as lighting, c-arm x-ray and many other details to carry out their
work.
This military regional hospital boasts 45 general doctors, 5 surgical specialists
(specializing in abdominal, trauma and thoracic surgery) with four (4) surgical
theaters available to operate 24/7. At the time of the assessment surgeries were
underway in 2 of the four. There are no CT, no MRI capabilities for imagining, 2 x-ray
machines, no c-arm x-ray and two ultrasounds with radiographers for operation.
Strength:
This is the main military hospital supporting this geographical region and has support
from Kyiv in healthcare staffing.

The culture of this facility is very negative to outside support. This facility does not
meet many standards associated with medical practice, lacks basic surgical supplies
and is not located close to the civilian airport where many patients are received. Due
to lack of CT imagining and other surgical equipment, this facility is NOT to be a
trauma receiving facility.
Conclusion:
This facility is a regional support medical hospital in need of drastic cultural change
and increased investment to completely overhaul its capability.
The above map depicts the Main Military Hospital
45
Dnepropetrovsk Airport Clinic

Description:
This is a 24-hour small walk-in facility for passengers traveling through the civilian
airport. It has access to a doctor 24 hours a day, on site roughly 8 to 12 hours a day
and 24 hour nursing support. There is a smaller backroom clinic with easy walking
distance to the military component of the airfield and there is a smaller more visible
clinic in the main departures lounge of the civilian passenger area before security.
Patient volume is roughly 12 to 15 per day and there are ECK and basic diagnostics
available. First aid and trauma capabilities at this smaller clinic are very limited.
Strength:
This small clinic is located very close the military operation for rotary and fixed winged
medical evacuation and can support when needed with staffing and supplies in time of
crisis or mass casualty.
This is a poorly staffed and kitted-out clinic with only the basics; the MD was not there
at time of assessment and may not visit or staff the clinic regularly.
Conclusion: this is a medical asset near a military installation at a major waypoint for
casualties. It may benefit to review this clinic and have close collaboration at the
airfield for winter operations (heating and running water are available on site and are
not available).
The photomap above highlights that proximity of the main rotary wing flight line and clinic asset .
Civilian!
Hospital!!
Proposed!new!landing!site!
for!MEDEVAC!helicopters!
and!not!the!main!airfield!!
! corner from the main

The photo image above highlights the proposed new landing site for the rotary winged aircraft around the
receiving trauma center in Dnepropetrovsk
46
Dnepropetrovsk Civilian Hospital Trauma Center

Medical Director: Dr. Yuriy Skrebetz
+380505759801
skrebets-ne@yandex.ru
Deputy: Dr. Shevchenko: shevchenko68.12@mail.24
Description:
This facility represents the definitive trauma one equivalent center for the region. The
medical director is very proactive and this hospital supports the region and major ATO
activities as it is the only facility in the region that can handle multiple system trauma.
There are roughly 500 doctors working out of this hospital, 1175 beds, with 5 separate
surgical departments and 30 surgeons. At the time of the assessment roughly 200 to
300 patients from the ATO had been treated at this facility with anywhere form 1 to 15
patients coming in per day. Urgent trauma patients come to this facility and less sever
patients go to the military hospital (please see Military Hospital Dnepropetrovsk).
The facility boasts 5 CT machines, 4 working and functional at time of assessment,
two (2) MRIs with three surgical theaters operational and full laboratory capability.
Many patients that had been received at the time of the writing of this report were
due to blast and sniper fire injury. There were many patients in the ICU with traumatic
brain injury, poly trauma and sepsis from infected wounds and prolonged transport
times to definitive care. Surgeons did comment that survival rate of poly-trauma
victims was getting better and that transport times were getting better from the ATO.
There was one case of gas gangrene infected wound from a GRAD rocket attack.
Strength: this facility is the de facto trauma center with full capability to support ATO
operations and advanced tertiary care.
This facility is in city center and is tied to essential services; it is not easily defensible
and cannot have a helicopter land on the roof. There is a military hospital 15 minutes
away which is dysfunctional and this may be the de facto receiving hospital in a mass
casualty or full-scale invasion operation.
Conclusion: This is a fully operational and functional trauma center that should be
used as a primary receiving hospital with other military assets in the area to be
bypassed and avoided. The change is rotary winged aircraft landing locations are
highlighted above.
Burn Hospital Dnepropetrovsk
Dr. Maxim Victorovich Kuzmin
Kuzmin-gb2@mail.ru
Description:
This facility is smaller and focuses on burn injuries from the civilian population and the
ATO. At the time of the writing of this assessment a total of 15 patients were receiving
burns related treatment from the ATO at this facility. There are 20 to 30 beds fit for
purpose of advanced and basic burn care. Surgical theaters are currently being
modestly refurbished and will still lack modern lighting, x-ray and anesthesia
equipment. This facility was very well managed and organized but drastically lacks
the basic resources to provide burn care to the injured war fighter and needs support.
Strength:
The geographical location of this burn center places it in the unique area to support
many injured war fighters as needed.
47

This is a very small and poorly supported hospital; it has limited capability for mass
casualties or multiple burn patients.
Conclusion:
If this hospital does not receive upgrades, reusable goods and medical staffing
support, other facilities should be assessed for advanced burn care.
61st Mobile Field Hospital
The photos above are a map and satellite view of the mobile field hospital. Due to security and location concerns, the exact
location has been kept obscured, you can see from the multiple green highlighted tracks, the location of the tents and hospital
within the tree line. In late August 2014, this mobile hospital was moved due to Russian Federation military incursion.
Description:
This tent city hospital has roughly 40 medical staff, 20 doctors, 8 surgical staff and 2
anesthesiologists. This mobile hospital sees between 60 to 120 patients in a 24 hours
period, 75% are in multisystem trauma, 5% isolated to abdominal trauma, 5% isolated
to thoracic trauma the rest are various illness such as pneumonia, cellulitis and
psychiatric presentations.
Strength:
This mobile hospital has moved to a new location by the time of the writing of this
report. It is mobile and this is an asset.
This is not a modern, adequate or safe place to use as a mobile hospital. Cold and wet
weather will greatly hinder or halt operations.
Conclusion:
This mobile field unit should be demobilized and replaced immediately.
Key Findings and Conclusions

Ukraine has undergone a social and political revolution with great violence. Presently,
there is an active anti terrorist operation (ATO) with a determined enemy that is
armed with myriad lethal weapons systems and military power. This snapshot
assessment was short and a comprehensive medical audit with quantitative data
collection and process observation will be needed in the future.
There are shortcomings with the present emergency medical and evacuation process.
These are highlighted by the military war fighter, paramedic and military doctors
lacking a standardized medical approach to emergency medicine; a dearth of Combat
Life Saver (CLS) training for all uniformed troops or First Aid Kits (IFAKs) and no in
48
place combat paramedic program. Further deficiencies include no purpose built rotary
wing medical evacuation aircraft and critical medical equipment or medical staffing for
such an asset. Finally, inadequate mobile military medical hospitals with deficient
capabilities are being used in the ATO and need to be upgraded and modernized.
Key findings
The anecdotal average time from point of injury of a soldier to first medical
contact is 20 60 minutes
o This gap needs to be shortened
The average time from point of injury to field hospital with surgical capability is
8 to 18 hours (in some instance, as long as two days these numbers have
lowered due to volunteer groups and transport support throughout the ATO)
o This length of time leads to further morbidity and mortality of preventable
death
Soft and durable surgical supplies in the ATO are inadequate for high patient
volume, winter weather and major multisystem trauma
The rotary aircraft used for medical evacuation are dangerous
o Contracting, procurement of used or new fit for purpose aircraft is a
priority
Individual first aid kits (IFAKs) with accompanied CLS training is roughly 5% of
uniformed troops
The special forces paramedic role with advanced trauma treatment capabilities
in the field is non-existent
There are no armored ambulance transport capabilities
o The contracting, procurement of new/used or production of new vehicles is
a priority
o There are Ukrainian firms that can fit such an order and are awaiting MoD
requests
Lastly, communicable diseases such as polio, gastrointestinal illness and tetanus
present a clear and present threat across the ATO and all of Eastern Ukraine
with inadequate access to consistent basic serves and hygiene, prevention and
vaccination
Key Recommendations and Urgent programming
All Ukrainian military are to be issued an individual first aid kit (IFAK) and
Combat Life Saver (CLS) training
Field and pressure dressings, updated tourniquets and airway adjuncts to
brigade level medical staff re-supply is acute
Re-usable surgical instruments, c-arm x-ray equipment and a minimum of six (6)
modern anesthesia machines for field hospitals and medical facilities supporting
the ATO
20 portable ultrasounds and training for medical staff to (eFAST)
Eliminate the in situ mobile hospitals 59th and 61st and replace with modern field
hospitals with updated surgical capabilities, emergency medical care,
diagnostics, life support facilities and weatherproofing these mobile hospitals
should be strategically placed to serve as combat support hospitals, have rotary
winged aircraft access and have encrypted communication access to regional
and central medical topside support
All doctors, nurses and medics working at the mobile field hospitals are to be at
or above the following standard:
49
o Train and practice to the International Trauma Life Support (ITLS) /

Advanced Trauma Life Support (ATLS) standards
o Conduct emergency medical management of trauma, triage, patient
assessment and re-assessment of patients upon arrival from the field /
smaller facility
o Be proficient with continuity of care rendered in the field to the CLS core
management principles and advanced practices
o Follow the concepts and methodology behind the Golden Hour of trauma
management
Civilian or military built for purpose rotary medical evacuation aircraft need to
be purchased or contracted for use throughout the ATO to transport the critically
ill and injured following international guidelines
300 to 500 current combat medic / medical doctors to be trained in the Special
Forces medic role with advanced medical bag (STOMP/STOMP II equivalent) and
full medical equipment
Dedicate and configure a fleet of APCs or other armored vehicles to function as
armored ambulance transport from active combat areas to casualty evacuation
points
Procure adequate supplies of the polio and tetanus vaccines for use throughout
the civilian, enemy and Ukrainian populations in the East
The medical administration office and Ministry of Defense need to make a clear
message to the international community what they need, what they will do with
assistance and metrics for its use.
Specifically, The Medical Administration and Ministry of Defense need to:
o Broadcast in a single voice the humanitarian and medical requirements by
donors and the international community to carry out their core mission
o Implement marketing strategies that clearly define the MoD and medical
administrations needs with evidence and internal audit, data collection
and specifically what resource requirements are lacking and which mission
essential equipment are needed
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ANNEX
52
Contents of Individual (improved) First aid Aid Kit (IFAK)
Combat Life Saver (CLS) curricula and course materials (Ukrainian and
English)
Pre-existing programming with the IFAK and Ukrainian World Congress
Special Forces (SF) Advanced Paramedic curriculum
Special Forces (SF) Advanced field bag contents
Allied Joint Medical Support Doctrine AJP-4.10(A) NATO
Medical Evaluation Manual AMEDP-27
Casualty Evacuation in the Contemporary Operating Environment: A

Monograph (Leona C. Knight)
NATO 9-LINE MEDEVAC
53

Medical Assessment - Ukrainian World Congress. July 28th - August 8th, 2014

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Ukrainian World Congress

Ukrainian World Congress Medical Assessment

John Quinn, MPH, MD

Ukrainian World Congress Medical Assessment

SELECTED MAPS OF UKRAINE

Ukrainian World Congress Medical Assessment

KEY FINDINGS AND GAPS

DATA COLLECTION AND METHODOLOGY

MAIN POINTS OF CONTACT THROUGHOUT ASSESSMENT

HOSPITAL FACILITIES VISITED

SCHEDULE AND TIME TABLE OF ASSESSMENT

LOCATIONS VISITED GRAPHICALLY

COMBAT TRAUMA: A VERY BRIEF OVERVIEW

COMBAT TRAUMA BEST PRACTICES

MECHANISMS OF TRAUMA: THE ATO IN ACTION

AK-47 AND SMALL ARMS

Ukrainian World Congress Medical Assessment

DR. ANATOLY ANDRONATTI MEDICAL DIRECTOR MEDICAL EVACUATION

MAIN MILITARY HOSPITAL KYIV

KEY FINDINGS AND CONCLUSIONS

CONTENTS OF INDIVIDUAL (IMPROVED) FIRST AID AID KIT (IFAK)

Ukrainian World Congress Medical Assessment

COB Contingency Operating Base

Selected Maps of Ukraine

Ukrainian World Congress Medical Assessment

Ukrainian World Congress Medical Assessment

Ukrainian World Congress Medical Assessment

Ukrainian World Congress Medical Assessment

Ukrainian World Congress Medical Assessment

Data collection and Methodology

Ukrainian World Congress Medical Assessment

Ukrainian World Congress Medical Assessment

Ukrainian World Congress Medical Assessment

Primary assessment lead with indigenous personnel discussing armored ambulance

Ukrainian World Congress Medical Assessment

Main Points of Contact throughout Assessment

Ukrainian World Congress Medical Assessment

Embassy of Canada in Ukraine

Ukrainian World Congress Medical Assessment

Volunteer Logistics to the ATO

Hospital Facilities Visited

Schedule and Time Table of Assessment

Emergency State Services DENIED access

Ukrainian World Congress Medical Assessment

Locations visited graphically

Ukrainian World Congress Medical Assessment

Climate and Terrain

Ukrainian World Congress Medical Assessment

The graphical representation above is of the average rainfall and temperatures,

Ukrainian World Congress Medical Assessment

Ukrainian World Congress Medical Assessment

Combat Trauma: a very brief overview

Ukrainian World Congress Medical Assessment

Ukrainian World Congress Medical Assessment

Ukrainian World Congress Medical Assessment

of pre-hospital trauma life support to the ATLS/ITLS/PHTLS standards and finally is

Ukrainian World Congress Medical Assessment

Mechanisms of Trauma: the ATO in action

Ukrainian World Congress Medical Assessment

AK-47 and small arms

Ukrainian World Congress Medical Assessment

White Prosperous (WP)

Ukrainian World Congress Medical Assessment