Surgeon Describes Realities of Conflict in War-Torn Country

“The world will not be destroyed by those who do evil, but by those who watch them without doing anything.” 
–Albert Einstein 

In 2021, I was approached to volunteer for Global Response Medicine (GRM), a nongovernmental organization (NGO) founded in 2017 to provide humanitarian aid to victims of natural disasters, conflicts, and war. GRM, a 501(c)(3), has conducted operations in 13 countries including Ukraine, where efforts began at the outbreak of the war in February 2022. GRM’s mission statement is clear—Save Lives. Period.

My first deployment was with a forward surgical team in Bakhmut, Ukraine. In 2023, I returned as the lead surgeon under a World Health Organization (WHO) educational grant. What I saw, what I did, what I learned, and what I felt likely will resonate with every surgeon.

Team 6 consisted of two special forces (SF) medics and me, with more than 38 years of combined experience in acute care, general surgery, critical care, emergency medicine, and administrative medicine. I was a reservist in the US Army Medical Command for 4 years. 

Upon arriving in Bakhmut, we observed extensive destruction, deserted streets, and shuttered schools, churches, and businesses. We operated out of a small, community hospital located 6 miles from the Russian front in three directions.   

The hospital campus consisted of four buildings. Our quarters were on the third floor of the hospital that was used for storage and housing hospital staff. Plumbing was archaic; the shower flooded due to poor drainage, and hot water was unavailable a third of the time. Used toilet paper was disposed of in trash bins.

Our beds were World War I vintage metal frames; the linen was not changed during our time there. Meals consisted of buckwheat porridge for breakfast, soup or borscht for lunch, and borscht or pasta for dinner. A nearby small restaurant run by two 80-plus-year-old sisters provided relief. When asked about their plans if Russia invaded, they resolutely replied, “We will never leave.” (Two translators were assigned to Team 6 to enhance communication with the locals.)

Patient Care

Daily patient volumes ranged from eight to 84 individuals in need of care. The hospital did not have an emergency room—the concept of emergency medicine as a specialty did not exist. Most of the providers were assigned by the military under martial law and lacked experience with war-related injuries. As a first-level receiving hospital, our objective was to assess, stabilize, and transfer to a second-level hospital as the patient’s condition allowed. Transfer was by ground and involved a 5-hour trip.

The patients arrived by ground ambulance from the battlefront and were triaged in the entrance hallway by an anesthesiologist who led the trauma team. A static x-ray machine was housed next to the hallway, but portable units did not exist. A computed tomography scan required patients to be transferred to another building and was rarely used. 

The resuscitation room was a cramped two-bed unit. Staff roles during resuscitations were poorly defined, and the anesthesiologist did the emergency procedures (i.e., chest tubes, central lines, intubations). A surgeon was only called when surgical intervention was needed. Resuscitation fluids were primarily crystalloid; blood products, albumin, and fresh frozen plasma were limited. A central venous line was the primary route for fluids, and bedside ultrasound was not routinely used.

Our team brought two portable units and conducted multiple exams per day for teaching, demonstrating, and as part of the patients’ exams. 

Surgery suites were on the third and fourth floors accessible by winding, narrow stairs presenting significant challenges for intubated patients. Only one elevator existed, and power was out frequently. No electrocardiogram monitoring was available during surgery. A C-arm image intensifier was available but could only be used by the orthopaedic staff.

GRM addressed these gaps early on by funding $600,000 for the purchase of equipment for multiple facilities.

Surgery cases predominantly involved blast injuries from artillery, mortars, land mines, and rockets rather than gunshot wounds. Amputations were guillotine with revision and closure deferred to the secondary facility. There was no Veterans Affairs-like resource available. 

We received a 22-year-old soldier who was hit by mortars. He and his fellow soldier laid in the mortar crater for 3 hours before they could be evacuated. The other soldier managed to crawl over to him to place tourniquets: one on the upper right arm, the other at the proximal left thigh.

He arrived 11 hours after the injury with the tourniquets in place. He underwent a right arm amputation at the shoulder and a left mid-thigh amputation. We petitioned Army command to get access to a specialized prosthetic rehabilitation program, and he was sent to Sweden. 

The ICU had basic hemodynamic monitoring, but we were not doing ultrasound volume assessment or focused assessed transthoracic echocardiography exams. The ICU consisted of six beds that were always filled. Patient information from the field was minimal. There was a neurosurgeon available, but intracranial pressure monitoring was rare. 

Three days after our arrival, we were privileged to meet with Gumeniuk Konstantyn, MD, PhD, commanding colonel of all Ukraine military surgeons. He asked about our approach to injuries and complications. Dr. Konstantyn’s goal was to extend training and education for his surgeons and develop protocols for common war injuries. 

The hospital census was continually changing due to the walking wounded being transferred, discharged, or kept for another 24 to 48 hours. The tourniquets’ time of application was not recorded. The nursing staff ratio was 1 to 10 or 20 patients. Families were required to provide a variety of patient care activities every day. 

In 2022, GRM was the only NGO authorized to provide direct patient care in this country, and as a result, our team witnessed an extensive array of injuries such as our very first patient. This individual was a 20-year-old female with a gunshot wound to her left leg and left chest with a sucking chest wound, large avulsion laceration of her right triceps, a comminuted right humerus fracture, and a comminuted right tibia/ankle fracture. 

Tube thoracostomy with vented dressing of the wound was done, and she was hemodynamically stable. We provided a Focused Assessment with Sonography in Trauma exam, which was negative, and she was brought to the OR for external fixation and wound debridement. And so, cases like this came and went for 19 days, sometimes all day and night.

Change of Objective

By 2023, the Ministry of Health and Defense deemed forward positions too dangerous for non-combatants. GRM shifted focus to surveying providers’ medical needs and developing training programs supported by a WHO grant. These initiatives included emergency medicine training program for Ukrainian providers, frontline provider training, and a surgical mini-fellowship program addressing pressing educational topics. 

GRM collaborated with the Department of Emergency Medicine at Temple University in Philadelphia, Pennsylvania, to create a condensed curriculum for 25 Ukrainian providers who would train other providers. 

The pilot surgical fellowship delivered focused and essential training in Lviv, Dnipro, and Kyiv. While I was the lead surgeon for the entire deployment, Lori Rhodes, MD, from the Temple Burn and Trauma Program, led most of the teaching for burns. The participants completed precourse and post-course evaluations. Instructors and trainees made daily rounds from 9:00 am until 12:00 pm, followed by a didactic 2-hour presentation with case discussions. Most participants had the post-course perspective that experiencing our system in action helped enhance their course work. 

GRM constructed a 2-week observational rotation for the Dnipro team at The University of Chicago Medical Center (UChicago) in Illinois. The Dnipro team was very impressed with the UChicago Trauma Department, and they were excited to return to Ukraine to model their system. GRM arranged similar rotations for five more teams. GRM is continuing to work with the frontline medical community in innovative ways.

Implications of War

In June 2022, we witnessed daily artillery barrages throughout the city. The evening prior to our departure, artillery struck a nearby building, causing damage to the hospital and prompting an evacuation order. 

By 2023, air raid sirens, artillery, rockets, and drones became a daily reality across Ukraine. Even in cities such as Kyiv, alerts to seek shelter were frequent, underscoring the nation’s transformation into a battlefield. Bakhmut was eventually overrun by what has been referred to as “the bloodiest battle of the 21st century” and “some of the fiercest urban combat in Europe since World War II.”

The war’s implications for counter-terrorism medicine extend to the potential for hybrid warfare within the US—an advanced strategy in which near-peer adversaries employ multiple forms of warfare simultaneously. Most Ukrainians feel the war started in 2014 with the Russian invasion of Crimea. From 2014 to 2019, approximately 25% of deaths in Ukraine’s conflict were civilians. In comparison, from 1950 to 2019, civilian deaths accounted for 13% to 86% of total fatalities in major military conflicts worldwide.

Ukraine experienced a 9% to 12% population displacement. If such an attack occurred on US soil, similar levels of displacement would affect 29 to 39 million people. This kind of military conflict also would result in tens to hundreds of thousands of patients, stressing our trauma care as well as the civilian/military co-management (which is the major take-home message for the US healthcare system). 

The Ukraine response to this war highlights its resilience despite limited resources and an underdeveloped medical infrastructure. The country’s reliance on NGOs like GRM, WHO, and international entities, exemplifies its determination to prevail. Despite limited resources, an immature trauma and mass casualty system, critical shortages of personnel and supplies, and severe financial constraints, Ukrainian providers delivered exceptional care with skill and dedication.

Acknowledgment

The author thanks and appreciates the review and suggestions of Andrea Lenier, MSN, APRN FNP-BC, GRM deputy director and chief program officer.

Disclaimer

Except where noted, the interpretation and opinions of this article are those of the author and do not reflect the official interpretations or opinions of the ACS, US military, GRM, or the governments of the US or Ukraine. No financial conflicts of interest were disclosed.

Dr. James Stone practiced acute care surgery, critical care, and emergency medicine for 38 years. He served in the US Army Reserves as a Lieutenant Colonel. He was a medical and administrative director of a Level II trauma center and was a consultant for multiple trauma centers. Dr. Stone is a certified medical investigator and spent 16 years as a special investigator for multiple agencies. Since 2022, he has volunteered for GRM in Ukraine.

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