SAN DIEGO—One morning in early October, Hnat Herych, MD, PhD, the chief of surgery at Danylo Halytsky Lviv National Medical University, stood at a window of his hospital in Lviv, Ukraine, and took a video of a fire burning nearby, its black smoke darkening the sky. The blaze erupted after a Russian rocket hit a neighborhood near Lviv’s Multidisciplinary Clinical Hospital of Emergency and Intensive Care. With 1,200 beds, it’s now one of the largest functioning hospitals in Ukraine. Inside the facility, staff prepared for an influx of patients.
Before the war, staff at the hospital provided care to children and adults with run-of-the-mill conditions: injuries from car accidents, cancer, appendicitis. Everything changed on Feb. 24, 2022, when Russian troops poured over the Ukrainian border and launched a violent war that has taken the lives of 200,000 Russian and Ukrainian soldiers, according to U.S. government officials. Nearly 7.8 million Ukrainians have become refugees, and another 6.2 million are displaced within their own country. The Office of the United Nations High Commissioner for Human Rights reported that more than 6,200 Ukrainian civilians have been injured and 9,300 killed up to Oct. 9. The actual figures are believed to be considerably higher, but proper accounting is impossible during the war.
Within days of the invasion, Ukrainian defense forces commandeered gauze and bandages from hospitals for distribution on the front line, Dr. Herych said. Nurses asked him what they should do for patients in the hospital—“not just the patient with injuries, but the patient with general surgery disease like acute appendicitis, cholecystitis and like that,” he said. There was no good answer.
Over the past 10 months, Dr. Herych and his colleagues have been on a crash course in learning to provide combat care to civilian and military patients while under threat of bombardment themselves. They’ve been assisted by a steady rotation of American, Canadian and European physicians and surgeons, many of whom are retired from military duty and came to Ukraine on trips set up by the American nonprofit organization Global Surgical and Medical Support Group (GSMSG).
“We have challenges now that we could not imagine before the war,” said Dr. Herych, 33, in an interview with General Surgery News in November. A day earlier, Russian forces launched new waves of airstrikes across cities in Ukraine. During attacks, Dr. Herych and his colleagues canceled elective procedures and hid their patients in shelters below the hospital, where there are two ORs and a four-bed ICU. They waited until it is safe and then they returned to operating.
He spoke with GSN as he was on his way to a local children’s hospital to operate on kids injured in a car crash. “I started work two days ago,” he said.
Health Infrastructure Targeted
Immediately after the invasion, Russian forces began a campaign to target Ukraine’s health infrastructure. According to the World Health Organization, the Russians have launched 688 attacks on Ukrainian healthcare facilities to date, affecting hospitals and clinics, pharmaceutical warehouses and factories, and ambulances. They hit 64 facilities in the first four weeks alone, according to reporting in the Washington Post. Dr. Herych’s hospital has never been hit directly, but debris from rockets has fallen onto the roof, and doors and windows have been broken by the blasts.
The attacks on health facilities, combined with Ukraine’s destroyed supply chains, have cut off steady access to medications and other medical supplies. At the Multidisciplinary Clinical Hospital of Emergency and Intensive Care, which was built in 1980, staff began to use equipment long out-of-date, like needles that are 40 years old. “We were feeling like we were in the, maybe, first or second World War,” said Dr. Herych, adding that before the invasion, his hospital was a technologically advanced facility with a da Vinci robot (Intuitive Surgical).
On March 13, 2022, Russian forces launched an airstrike on a military training facility 25 miles from Lviv. One hundred patients from the bombing arrived over the next hours, he said. “We never had the experience to have 100 patients with injuries that needed to go straight into the operating room.” Thirty-five people died in the attack.
Lviv’s Multidisciplinary Clinical Hospital of Emergency and Intensive Care is about 40 miles from Ukraine’s border with Poland and hundreds of miles from most of the fighting, but Dr. Herych and his team have treated more than 6,000 patients with war-related injuries, including 314 civilians and 242 evacuated military personnel who required surgery.
People who are injured in the east continually move westward, receiving more definitive care as they get further from the front lines. Many hospitals in the east are no longer fully operational. In Lviv, Dr. Herych and staff care for severely injured soldiers who arrive after being transported by passenger trains that have been converted for medical transport, a journey that can take several days or more. The injured often present with wounds that have multidrug-resistant infections. At the same time, he and colleagues treat civilians who’ve been injured by bombs or collapsing buildings, and they continue to provide care for Lviv’s swelling population.
In October, Dr. Herych came to the American College of Surgeons Clinical Congress, in San Diego, where he gave a presentation about surgery in Ukraine. He was joined by seven American surgeons who have rotated through Ukraine since March 2022. The panel described a war that is causing a high number of severe injuries, spread across people of all ages who are being treated by a civilian workforce.
“This is a real modern war because both sides use an artillery system, so we have a lot of shrapnel injuries,” Dr. Herych noted. “The direct contact of the militaries [is] a real killer, but also we see the patients who are newborn, small patients and old patients.”
John B. Holcomb, MD, a professor of surgery at the University of Alabama at Birmingham, joined the U.S. military in 1985, and was deployed later as a surgeon to Somalia. There, he and his team once operated for 48 hours nonstop, looking after people wounded in the Battle of Mogadishu. After returning to the United States, he focused his efforts on improving combat casualty care and led massive changes in American medicine as the chief of military trauma research at the U.S. Army Institute of Surgical Research (USAISR), and eventually commander of USAISR and trauma consultant to the U.S. surgeon general. Under Dr. Holcomb’s leadership, the military provided tourniquets to all Americans deployed in combat zones and introduced the use of hemostatic dressings. He revolutionized damage control resuscitations, adopting whole blood to treat trauma patients. This change grew out of his work in Somalia, when faced with no other choice in the battle made famous in the film “Black Hawk Down,” he began to use whole blood to resuscitate injured patients.
In the spring of 2022, Dr. Holcomb went to Ukraine with GSMSG for the first time and has returned twice to help train local surgeons in trauma care. He described the conflict in Ukraine as a “very violent war. There are lots of casualties, military and civilian, on both sides of this equation.” The weapons used are the same as those in other conflicts, based on his limited viewpoint, Dr. Holcomb said. Like in Iraq and Afghanistan, the majority of injured people are civilians, he said. But their injuries differ: In Ukraine, civilians present mostly with wounds from air attacks and collapsing infrastructure rather than from improvised explosive devices, he said.
“Russians [are] shelling civilian installations and hospitals, and collapsing buildings on purpose as a strategy. You see the crush injuries and compartment syndromes. That is different. We saw a little bit of that in Afghanistan and Iraq, but not to this extent,” Dr. Holcomb said.
He said he has not seen a conflict in which the aggressor targets healthcare facilities the way the Russians are doing. “I think all of us kind of get a punch in the gut when we see that.”
GSMSG: Building Capacity in a Conflict Zone
In 2014, Aaron Epstein—then a medical student, now a fourth-year general surgery resident at University of Buffalo—started GSMSG. Dr. Epstein, previously worked in national security and defense focusing on the Middle East. Overseas, he felt that too many aid organizations came into conflict zones, treated patients or dropped off supplies, then left without creating lasting benefit for residents who remained behind. He founded GSMSG to provide medical relief and training in conflict zones, with the goal of building enough expertise among the local population to render his organization obsolete in the area. (A video interview with Dr. Epstein at the American College of Surgeons Clinical Congress can be viewed here.)
The organization sends primary care and surgical teams, including trauma/critical care, orthopedics, neurosurgery, vascular, cardiac and thoracic, for two-week rotations on the ground. Beginning March 2022, the organization posted surgeons, physicians, nurses and medics in Ukraine. They taught Advanced Trauma Life Support and Stop the Bleed courses across the country for medics and civilians, and worked in hospitals, clinics and far-forward settings. They also organized remote educational training, leading Zoom seminars in combat care and translating into Ukrainian the U.S. DoD Combat Casualty Care course. So far, GSMSG has trained more than 20,000 Ukrainians, including medics, nurses, physicians and surgeons. In July 2022, Dr. Epstein received a Citizen Honors Award from the Congressional Medal of Honor Society for his work.
“Our niche area is really training and building capacities,” he said. Other aid organizations specialize in bringing in much-needed supplies. “But I would say for us, in particular, we bring the human capital to really focus on building capacities.”
A Revolution in Whole Blood Use
During the Vietnam War, the American military pioneered the use of blood components, colloids and crystalloids in transfusions, thereby increasing the number of patients who could benefit from a single blood donation. Over the next two decades, component blood therapy became standard in prehospital and hospital settings. By the end of the 20th century, whole blood was eliminated for civilian procurement and therapies in the United States.
Similarly, in Ukraine, whole blood was not used for resuscitations for decades. The government had passed laws making it illegal, reflecting the long-held idea that component therapy is the standard of care and the best use of a lifesaving but limited resource.
However, during operations in Afghanistan and Iraq, American military medical forces faced shortages of platelets. Platelets have a five-day shelf life and needed to be shipped from the United States, Dr. Holcomb said. This shortage led to a renewed interest in his experience in Somalia with use of whole blood. “When we started looking at the outcomes of patients with whole blood, they are as good or better,” he said. In 2016, U.S. military special operations teams began receiving low-tier group O whole blood for use at the point of injury. Since then, whole blood has become the standard for the American military and is used at about half of the Level I trauma centers in the United States.
In Ukraine, Dr. Herych and the international team of volunteers developed a system for whole blood transfusions in the Lviv hospital. They took their results to the Ukrainian Ministry of Health, and within two weeks convinced the government to change the transfusion law. The Ukrainian Ministry of Health has adopted a policy of using whole blood to resuscitate severely injured patients in the hospital and prehospital settings.
“I would say, in the civilian world, it takes 47 meetings and about 18 months to change over to whole blood,” Dr. Holcomb noted. “[Dr. Herych] and colleagues in a time of war, when the Russians are invading their country, had an imperative to change that in two weeks.”
Challenges for Burn Patients
Ukrainian medical services see a high number of civilian and military patients suffering with burns, said Steven E. Wolf, MD, a professor and the chief of the Division of Burn, Trauma and Acute Care Surgery at The University of Texas Medical Branch, in Galveston. Between 2004 and 2011, Dr. Wolf was the director of the burn center and later the director of clinical research at the United States Army Institute of Surgical Research, in San Antonio/Houston, where he supervised the care of military casualties who had suffered burn wounds in Iraq and Afghanistan.
Treating patients with burns has always been a large part of wartime medical care, Dr. Wolf said. Since the invention of gunpowder, about 10% of war casualties are burns or burn related, he said. Civilians and military personnel become burned as a result of weapons or building fire. But there’s also an increased risk for burns caused by the upheaval in the lives of residents. They end up living in unsafe structures, and warm themselves and prepare food over unreliable heat sources.
Dr. Wolf and others worked with Ukrainian medics and front-line providers on how to manage wounds and keep them clean. But the process of getting patients from the point of injury to more definitive care is slow in Ukraine. Personnel who are injured serving at the front are often hundreds of miles from a fully functioning hospital and have no speedy transit system for evacuation. That situation is very different from the U.S. experience in Iraq and Afghanistan, where the military developed an efficient system to move the injured out of a conflict zone and into Germany within a matter of hours and then to the United States within days. No such system exists in Ukraine. The country’s transportation routes are destroyed, making vehicular travel difficult. Airplanes cannot fly in and out. Many injured people are put on trains, where they are cared for by civilian and miliary medics, and eventually arrive in hospitals in cities farther west. It can take four to five days to get patients to Lviv from the east. “We have not seen this kind of care on trains and transport by trains since World War II,” Dr. Holcomb said.
This system saves lives but can increase the risk for wound infection if injured people do not receive regular care on the way. The standard of care is to begin early grafting on burn patients within 48 to 72 hours, Dr. Wolf noted, but that is not always possible in Ukraine. There are significant delays in closing wounds and initiating grafting, which will have long-term complications, he said.
“Everybody’s doing the best they can, but you cannot make the assumption that somebody is going to show up in your burn center within 48 hours,” Dr. Wolf said. The longer patients wait for wound care, the more problems they will have, he added. “They’re going to have a bad scar; there’s going to be a lot of functional problems; there’s going to be a lot of cosmetic problems that we’re going to have to deal with.”
Long-term consequences for burn patients in Ukraine are unclear. Currently, convoys of ambulances help transfer severely wounded patients to Poland, many of whom are then taken by medevac throughout Europe for treatment, reconstruction and rehabilitation. In Lviv, Dr. Herych and his team do reconstructive surgery, but there are more patients with injuries than available beds and services.
This will be problematic in the months to come, Dr. Wolf noted. Burn patients require extensive care for many years. “It may be that half your body or more is one big sheet of scar, and a lot of physiologic changes are going to occur. These stabilize out after about a year and a half. The beginning of the game in burn care is closing the wound. There’s a long game that goes on after that.”
Telemedicine Comes Into Play
Different organizations have built a telemedicine system between Ukraine and the United States and Europe. Telemedicine robots, sent by World Telehealth Initiative, were set up in Lviv in May by Warren Dorlac, MD, medical director of trauma and acute care surgery at Medical Center of the Rockies, UCHealth. Dr. Dorlac served 26 years as an air force surgeon, becoming chief of trauma and trauma medical director at Landstuhl Regional Medical Center. Later, he directed the U.S. Central Command’s Joint Trauma System, where he oversaw trauma care units in Iraq and Afghanistan in 2009.
Telemedicine helps physicians abroad work closely with Ukrainian doctors. From Washington, Rocco A. Armonda, MD, a neurosurgeon who spent 30 years with the military before joining Washington Hospital Center, has collaborated with a neurosurgeon in Lviv to treat patients. The two surgeons set out operative plans, but the Ukrainian hospital lacks equipment for surgery. Dr. Armonda collected 14 tubs filled with neurosurgical equipment and drove them to Newark, New Jersey, to meet volunteers bound for Ukraine.
“I don’t think people realize how many casualties are in Ukraine,” said Dr. Armonda. “It’s more than we had in Vietnam, more than Iraq and Afghanistan.”
Ongoing Shortage of Medical Supplies
Surgeons said Ukraine is hampered by a shortage of basic medical supplies, and this is contributing to rates of severe infection and even deaths. Hospitals lack bandages, medications, antibiotics, blood bags, sutures, negative-pressure wound therapy devices, external fixers, anesthesia machines for patients during transport, and blood heating devices, according to the surgeons who spoke at the ACS meeting. Gauze remains in short supply, given the high number of burn patients. “To do wound care on somebody with a burn wound, it is going to take a month, and you have to change them every day. You can run things out very quickly,” Dr. Wolf said.
The lack of medical supplies is a leading cause of the wound infection rate, Dr. Dorlac said. “If you get an infection in one patient and they’re [sharing] a room with someone, at the end of the day, everybody else has it. If you can’t do the basic stuff in infection control, there’s going to be more difficult and bigger problems in the end.”
At the Polish border, trains and trucks are lined up to get into Ukraine with supplies, but it is not enough, Dr. Holcomb noted. He called for an increase in medical aid to Ukraine. “I would love to make a plea to all of the Western governments now: Supply substantial medical, nonlethal aid to the Ukrainians for their civilians and military. It’s extraordinarily important that we help them do that.” He added that arms aid to Ukraine should continue.
National Rehabilitation Center Under Construction
The Lviv Medical Association is working to build a national rehabilitation center, called UNBROKEN, which will be part of the same hospital system as the Multidisciplinary Clinical Hospital of Emergency and Intensive Care. UNBROKEN will be similar to the U.S. Center for the Intrepid, a rehabilitation facility for military personnel suffering amputations, limb trauma and severe burns. The Ukrainian facility will provide care to military and civilian patients, adults, and children, and will provide postsurgical, physical, psychological and psychosocial support. It will also increase the production of prosthetic and robotic devices, and help patients learn to use them.
The project is currently accepting donations. More information is available at www.unbroken.org.ua.
GSMSG is looking for volunteers with prior U.S. special operations experience and who are surgeons, anesthesiologists/CRNAs, PAs/NPs, critical care nurses or paramedics. Anyone interested in working with GSMSG is asked to contact the organization directly at www.gsmsg.org.
This article is from the December 2022 print issue.
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