On February 24, after months of uncertainty, military preparations, and posturing, Ukraine was attacked by Russian missiles and invaded by troops from Russia and Belarus in the north and Crimea to the south. This war is not new, but rather an extension of an earlier conflict that started in 2014 after the Revolution of Dignity (aka Maidan Revolution), which forced the resignation of President Yanukovych, the annexation of Crimea by Russia, and separatist movements in the Donbas region. Intermittent but continuous fighting has been ongoing since.

Today, more than two months after the initial escalation of the conflict, thousands of lives have been lost and millions have been displaced. The war continues due to a strong Ukrainian resistance in the face of the obvious advantages of the Russian armed forces. As a result, to date, few military objectives have been achieved by the Russian forces. The resultant humanitarian crisis has led to over 4.5 million Ukrainians (over 10% of Ukraine’s population) having fled to surrounding countries and 7.1 million people becoming internally displaced. As a result, over 12 million people are in need of aid, including medical care, food, water, and shelter.

Civilian casualties have been widely reported. Thousands of missiles, airstrikes, and daily artillery shelling have been documented striking civilian targets, leading to more civilian than military casualties. As of late March, 570 educational institutions, 150 health facilities, 4,500 residential buildings, and 59 religious buildings have been damaged or destroyed in Ukraine. Reports from some of the most affected cities of Kharkiv and Mariupol have shown over 1,000 and 2,000 buildings destroyed, respectively.

Brief timeline of major events:

24 February 2022 – Russia begins the invasion with artillery shelling, missile strikes, and land invasion

25 February 2022 – Russian forces occupy Chernobyl power plant

1 March 2022 - Siege on Mariupol begins

4 March 2022 – Artillery fire around the largest European nuclear power plant in Zaporizhzhia prompts concern for a nuclear catastrophe

15-16 March 2022 – Mariupol hospital taken over by Russian troops and 300 people killed in an airstrike on a shelter at the Drama Theater in Mariupol

29 March 2022 – Russia halts operations in northern Ukraine, pulling back from the capital

3 April 2022 – Evidence found of mass killings in Bucha and other surrounding towns near Kyiv

8 April 2022 – 52 casualties and 100 wounded at the main train station in Kramatorsk as civilians attempt to board trains for evacuation

14 April 2022 – Russian battleship Moskva sinks in the Black Sea after being damaged from a reported Ukrainian missile attack

18 April 2022 – Renewed Russian offensive in eastern Ukraine begins, with increased bombardments of civilian and military targets and Russian officials state goal to take the entirety of Donbas and Southern Ukraine

Casualty Estimates:

• Extremely unreliable numbers with diverging reports from Russia, Ukraine, and various independent sources

• Civilian: ranging from several thousand to tens of thousands of deaths, with an unknown amount of injured and large numbers of children being affected

• Ukrainian Military: Ukraine reports up to 3,000 deaths of Ukrainian armed forces, U.S. officials estimate causalities to be 2,000-4,000

• Russian Military: Russia reported 1,351 killed with the NATO estimate for Russia and their allied forces significantly higher at 7,000 to 15,000

Medical situation on the ground:

This military conflict has created unique challenges for the medical personnel on the ground in Ukraine. There has been widespread destruction of infrastructure in major cities leaving its already chronically underfunded healthcare system on the verge of collapse. Less affected cities in western Ukraine and the capital, Kyiv, have been able to fill the gaps for those casualties able to be evacuated. Medical support in the form of international materiel and personnel has also provided some relief. Below is a summary of the unique challenges being faced by medical professionals in Ukraine.

1. Emergency medical care in Ukraine has evolved significantly in the face of the influx of civilian casualties and disruptions to infrastructure. While medical care in Ukraine is physician-led, it has not traditionally been prepared to handle mass casualty incidents. Physicians of various specialties have stepped up and trained in the essentials of trauma resuscitation, including the TCCC/MARCH assessment, burn management, traumatic brain injury, and even treatment of radiological injuries and mitigation of exposures.
2. Ukrainian prehospital care has been transitioning from physician-led (Franco-German model) to the paramedic-led (Anglo-American EMS model) over the past 10 years, with two-thirds of EMS teams being paramedic-led as of 2020. Prehospital providers have played an essential role in providing care in extreme wartime environments. Unfortunately, many casualties have been reported among such medical providers.
3. Tactical Combat Casualty Care (TCCC) and MARCH assessment have been the standard combat casualty training provided to U.S. armed forces. TCCC training and MARCH assessment has been implemented by the Ukrainian armed forces since the beginning of the conflict in 2014. Since the recent escalation of conflict, TCCC training has been extensively distributed through official channels and many online videos and training materials, including the United States Joint Trauma System (JTS) Emergency War Surgery and Stop the Bleed courses have become freely available in Ukrainian. MARCH assessment principles have been encouraged to be used by not only the military and territorial defense, but also civilian healthcare providers, EMS, and volunteer groups. Unfortunately, initial reports indicate highly variable training levels and application of TCCC and MARCH principles.
4. Medical supplies have been provided by major contributors like USAID and through local efforts, such as the donations coordinated by Dr. Maksimenko with the San Antonio Fire Department. In particular, tourniquets and other trauma wound care supplies have been donated in large quantities; however, some reports indicate unequal distribution within the country and only cheap, poor-quality tourniquets are ending up in the hands of those that need them most.
5. Blood products for resuscitation are being used, however, supplies are limited. Efforts to establish a robust whole blood and blood product supply from outside of Ukraine have not been successful to date.
6. Care of not only those wounded in combat, but also of the chronically ill and pediatric patients has had to take place in austere settings, such as the deep underground metro stations of cities like Kyiv. Nurseries and NICUs have been famously run in those limited resource settings. Targeting of healthcare facilities has made care for the critically ill increasingly difficult and dangerous.

Medical needs and ways WMS Members can help:

1. Public distribution of training materials in Ukrainian, such as Stop the Bleed, TCCC Course and JTS Manual
2. Stop the Bleed/TCCC/MARCH supply collection and shipment
3. Stop the Bleed, TCCC, emergency medical skills virtual instruction
4. Coordinated involvement of foreign medical volunteers for in-person instruction as well as direct medical care in Ukraine and surrounding countries
5. Fundraising (see below organizations)
6. Medical record interpretation – for example St. Jude’s Children’s Research Hospital is treating pediatric patients from Ukraine and has a call out for Russian- and Ukrainian-speaking physicians to assist with record interpretation
7. Telemedicine services and support to Ukrainian physicians – for example the Ukrainian Medical Association of North America and the ViveoCares Foundation are both making virtual tele-visits available for patients and for medical provider consultation in Ukraine

Organizations supporting the victims of the war in Ukraine (vetted by authors):

1. Doctors Without Borders/Médecins Sans Frontières (MSF)
2. International Medical Corps
3. Refugee Relief International
4. Global Response Management
5. Stop the Bleed Donations
6. Ukrainian NGO Coordination Network

Disclaimer: The views expressed are those of the authors and do not reflect the official views or policy of the Department of Defense or its components.

Photos (various sources, keeping anonymous for security):