In Ukraine, the Triumph and Tragedy of Battlefield Medicine

CHERKAS’KE, Ukraine—It takes about 10 minutes to drive to the highway from the Ukrainian army base in this small town. From there it is 130 miles, about a three-hour drive over Ukraine’s pothole speckled roads, to the front lines in the Donbas.

The war is close, both in distance and in the futures of the men training here for it.

In a wide-open field on the Ukrainian steppe on a hot, end of April afternoon, about 30 soldiers of the regular army’s 46th Battalion Donbas are training in Tactical Combat Casualty Care, or TCCC.

Half of the soldiers are lying on the ground, simulating having been shot. Standing about 30 yards away, their rescuers call out, asking where their comrades are hurt and then to announce that help is on the way. This is important to do, so as not to startle a wounded, scared soldier lying helpless with a weapon.

The rescuers low crawl across the ground to the wounded men. They stay low to the earth, reducing their profile to avoid being hit by bullets or shrapnel. One soldier pokes his head up to get a look at where he’s going, and WHACK, he’s clobbered on his helmet-covered head by a canteen.

Wielding the canteen is the group’s instructor, Ivan Kondratenko, 37.

“Keep your heads down,” he yells. “Heroes never die. But it’s better to be a living hero.”

Kondratenko is a military medical doctor with a civilian practice, who for more than a year has volunteered every weekend and often gives up evenings during the week to train soldiers in Tactical Combat Casualty Care. TCCC was created by the U.S. Army in response to casualty trends in the wars in Iraq and Afghanistan and is now the NATO standard for battlefield first aid. The training focuses on the immediate care of battlefield injuries while still under fire.

Many of the techniques Kondratenko teaches he says he learned from NATO trainers who visited Ukraine in the early days of the war.

“I teach them TCCC, but I adapt it for our reality,” he says.

He knows most of these men will be on the front lines in a matter of days or weeks. As the soldiers run through their drills, Kondratenko paces back and forth with a Kalashnikov rifle slung over his shoulder, shouting commands in a booming voice one would more likely expect from a U.S. Marine Corps drill instructor than a civilian doctor.

Every so often he smacks a soldier’s head with his canteen. But in between his shouted commands, he frequently leans down close to his low-crawling pupils, almost whispering advice and instruction in their ears.

“I could be home relaxing, but I have to be here,” he says. “I know the things I’m teaching them will save their lives.”

Kondratenko comes across as being hard on the soldiers. But it’s a role he must play for the sake of the men’s training. Before teaching soldiers how to apply a tourniquet, he puts them through a series of physical exercises, pushing them to exhaustion. Physical exercise simulates the physiological responses to combat, and Kondratenko knows that if the soldiers ever need to use the skills he is teaching them today, they will have to do so under extreme stress.

“I make the training very hard,” Kondratenko says. “I’m tough, but the price of a mistake in combat is death. We have lost a lot of really good people, and we’re tired of burying our boys.”

From time to time Kondratenko’s more empathetic demeanor shows through. Like when he tries on a helmet that is a bit too small and the strap digs into his neck, causing him to gag. A few soldiers chuckle and Kondratenko cracks a smile from beneath his sunglasses.

After a few exhausting minutes of hauling themselves across the dirt and scrub grass of the Ukrainian steppe, the low-crawling rescuers finally reach their simulated wounded comrades. In a series of orchestrated movements they inspect their patient for injuries, looking for hidden bullet and shrapnel wounds, and then apply tourniquets to injured limbs. Kondratenko observes and inspects the tourniquets. If satisfied, he pats the men on the shoulder to let them know they’re finished.

When the drill is over, the soldiers stand up, dust off the dirt from their body armor vests and uniforms (which range from Kappa track suits to U.S. military multicam) and prepare to go again.

“It usually takes six months or a year to train a soldier,” Kondratenko says. “But our guys only get one or two months.”

“We don’t need more weapons,“ he adds. “We need more time, more medicine, better training and better leaders. And we have all these problems while the enemy is in our land.”

Health Care Shortfall

Effective medical care has been among the Ukrainian army’s most pressing shortfalls since the conflict with pro-Russian separatists began last spring.

About 95 percent of Ukraine’s combat deaths occur on the battlefield, underscoring the need to train front line soldiers in combat first-aid. According to U.S. Army data from Iraq and Afghanistan, 90 percent of U.S. battlefield deaths occur before soldiers reach a hospital.

The added challenge for Ukraine, however, is that the separatist surface-to-air missile threat has grounded Ukraine’s medevac helicopters. The wounded have to be evacuated by ground transportation, which often includes civilians who volunteer to use their personal cars as ambulances.

Emergency medical personnel often speak of the “golden hour” to get a traumatically wounded patient to a hospital—a critical window for providing medical care that significantly improves the chances of survival.

But wounded Ukrainian soldiers often spend hours on the battlefield before they are evacuated, and Ukraine has only just begun to set up MASH units near the front lines, requiring many wounded soldiers to make long journeys to the nearest local hospitals before they see a doctor.

“We lose a lot of soldiers because we can’t get them off the battlefield in the golden hour,” Kondratenko says. “In our situation it takes a lot longer. We teach soldiers with the understanding that you have to take care of the victim for several hours.”

Kondratenko says many Ukrainian doctors are inadequately trained to deal with the types of wounds soldiers suffer in combat. Yet, he adds, it is more important to focus on training soldiers in tactical first aid since most deaths occur before patients ever see a doctor.

“The majority of battlefield deaths are from survivable injuries,” he says. “My goal is to focus on the soldiers first to reduce that 95 percent number. If we can do that, we are going to save lives.”

According to U.S. Army research, 60 percent of preventable combat fatalities are due to catastrophic blood loss, 30 percent from tension pneumothorax (the buildup of air pressure in the chest after a lung laceration), and 10 percent from blocked airways.

To treat these injuries, Kondratenko harps on the use of tourniquets, analgesics, and hemostatic devices like QuikClot, which accelerate blood clotting and stop bleeding. But these types of medical supplies are scarce in Ukraine, so Kondratenko teaches soldiers to make use of everyday materials for their battlefield medical kits. They buy women’s panty hoes to use as tourniquet replacements, and scotch tape for dressings.

“That’s our soldiers’ reality,” he says. “In some situations they have only their hands to use to save themselves or a friend.”

The Ukrainian military is still largely reliant on volunteer donations for many supply staples, including Improved First Aid Kits (IFAKs), which soldiers use to treat themselves or comrades, making them less reliant on medics.

Patriot Defense, for example, a Ukrainian World Congress program largely funded by Ukrainian diaspora, has so far delivered 13,023 IFAKs to the Ukrainian military. The program has also trained more than 15,000 military personnel in TCCC.

The slow pace of battlefield evacuations presents Ukrainian soldiers with another challenge. They have to also consider the long-term impacts of the short-term techniques they use to save lives. The fate of wounded limbs may ultimately depend on soldiers knowing how frequently to loosen tourniquets and change dressings.

“We have to think about not just saving a soldier’s life, but saving their health,” Kondratenko says. “Once the life is saved, they need to know how to save the limb. There have been instances when wounded soldiers have been pinned down in combat for more than 12 hours with a tourniquet applied.”

Tragedy of Lives

Sometimes the triumph of battlefield medicine is overshadowed by the ensuing tragedy of lives, which, while spared from death, will be lived in ruined bodies and sometimes shattered minds.

You see evidence of this at a military hospital in Cherkas’ke, where Igor Datsonov, 47, is lying in a third floor room with the window curtain pulled back to let the afternoon sun come in.

He has the room to himself, except for his mother, 76-year-old Varvara Datsonova, who is at his side. Neither say anything.

At first, there appears to be little wrong with Datsonov. There are no visible wounds or scars. He lies in bed wearing a sweatshirt with the sheets pulled up to his chest. His left arm is out from under the covers. His other arm and both legs are covered, but their outlines reveal that all limbs are intact.

Datsonov’s injuries are not immediately visible, but you quickly realize how serious they are.

He was shot in the head and the leg in a battle outside Donetsk on Jan. 15. He’s now a cripple, unable to move the right side of his body or control his bladder. Under the sheets he’s naked from the waist down, lying on an absorbent pad. His hair has mostly grown back over the scars and misshapen part of his skull where the bullet entered, but his mind has never fully recovered. As he talks, his eyes drift lazily across the room, blurring out of focus.

Every so often his eyes come alive for an instant. He focuses on yours and speaks a sentence or two as he holds on to a thought. But then he’s gone again. His pupils fade out of focus, and his sentence trails off.

He speaks like this, in sputters and stops. When the energy of conversation overwhelms him, he stops to close his eyes, lick his lips and swallow with a loud smack before briefly drifting out of consciousness.

As he slides away, his mother says something to spur him to talk. Datsonov’s eyes open, lost in space, staring aimlessly at the ceiling above before descending to absently meet the faces of people in the room, as if you had only just arrived.

The conversation goes like this for a while. But he was able to explain what happened to him.

He said his 15-man squad was ambushed in a battle outside Donetsk; four were killed in the attack.

“The separatists shot us like they were playing chess,” he said. “They didn’t shoot everyone, just the ones they wanted.”

He doesn’t remember when he was shot or how he was evacuated from the battlefield. He only vaguely remembers waking up from a coma two months later.

“It’s very hard to see him like this,” Datsonova says of her son, who was a Ukrainian army captain when he was wounded. “It’s hard for me. He yells at me a lot. And I can hear him crying in the night.”

Dotsonov was discharged from a hospital in Dnipropetrovsk where he was initially treated, but after a few weeks at home his condition deteriorated and he was admitted into the Cherkas’ke hospital for long-term care.

“They’ve been giving him medicine, but nothing has helped,” Datsonova says.

Dotonov’s case underscores the long-term challenges of caring for wounded veterans. Dotsonova says all of her son’s basic medical care is paid for by the military, but she is on her own to find specialists such as physical therapists and psychologists who might help rehabilitate her son.

Despite her son’s injuries, Datsonova still supports the war, calling it a “fight for Ukraine’s freedom.”

“I hope that peace will come soon,” she adds. “I always have hope for peace.”

Her son’s eyes focus for a brief instant.

“Forget about peace,” he says.