Russian Forces Attack Marked Ambulance in Kupiansk

 

This marked ambulance was attacked by a Russian FPV drone in Kupiansk. The driver was hospitalized with blast injuries.

Video: Russian Drone purportedly dropping Petal Mines over Ukrainian Territory

 

Trump's 27 Jan Peace Proposal:

By May 9, 2025, a declaration of the end of the war and the lifting of martial law in Ukraine - these are the main provisions of Trump's "100-day plan" for Ukraine

This plan of the US president was allegedly transmitted through European diplomats. Its main stages are:

1. January-February 2025: Trump's telephone conversations with Putin and discussion of the plan with the Ukrainian authorities.
2. February-March 2025: Zelensky must repeal the decree banning negotiations with Putin.
3. April 20, 2025: Declaration of an Easter truce along the entire front line.
4. End of April 2025: launch of the International Peace Conference to conclude a peace agreement mediated by the US, China, European countries, and the "global south."
5. By May 9, 2025: declaration of the end of the war and the abolition of martial law in Ukraine.
6. August-October 2025: holding presidential, parliamentary and local elections.

Parameters of the peace agreement:
Ukraine declares neutrality, rejection of NATO, and preservation of an army with US support.
Accession to the EU by 2030 and post-war reconstruction at the expense of the European Union.
Ukraine does not recognize the sovereignty of the Russian Federation over the occupied territories, but refuses to return them by military means.
Gradual lifting of sanctions against the Russian Federation and resumption of imports of Russian energy resources to the EU.
Ending the persecution of the UOC and the Russian language, allowing "pro-Russian" parties to participate in the elections.
The issue of the European peacekeeping contingent remains controversial and requires additional consultations.

Maggot Wound Therapy

Modern medical acceptance of using maggots for wound debridement is growing. 

 Indeed, some companies even produce certified, clean medical-use maggots. Wound-cleaning maggots should be types which feed on dead tissue only. This includes green bottle flies, which are very common and endemic almost everywhere. Natural colonization of open wounds by green bottle flies may occur if the wound is left open, although there are fly species whose maggots feed on living as well as dead tissue.

Maggots have mouth parts composed of two hooks, which which they grasp food before liquifying it with digestive enzymes and consuming it. They are adept at cleaning out nooks, crannies, and overhung parts of the wound, which would be difficult to access with other methods. Maggots are covered in tiny microscopic spines, which help to physically loosen necrotic tissue as they move across the wound. Physical removal of bacteria by maggots disrupts the bacterial biofilm which can make it difficult for antibiotics to penetrate, and prevent chronic wounds from healing. Maggots aren't impacted negatively by antibiotics or narcotics, and can be used as an adjunct to these treatments. Their digestive juices actively promote wound healing and re-vascularization.

Ideally maggots should be placed directly into the wound; however they may also be placed on the wound in mesh bags. This is less effective, but may also be less painful for some wounds, such as burns.

A typical treatment consists of placing maggots, then cover the wound for 2 nights with a cage dressing (this can be made from a simple object like a cutoff shirt sleeve, taped over the wound). Maggots only feed for 2-3 days before becoming ready for their next life stage, so they are ready to be gently irrigated out of the wound after treatment. Patients generally require 3-6 treatments, over the course of 1-3 weeks, for complete debridement.

Ukraine: AntiMicrobial-Resistant Infections

Below:  lung cavities, caused by XDR Tuberculosis

Unfortunately, various Antimicrobial-Resistant infections are widespread and rising in wartime Ukraine. This is just one facet of a worldwide challenge; WHO recently predicted that AMR infections could surpass cancer as the leading cause of death worldwide by 2050. 

Bacterial resistance is predominantly caused by the misuse or overuse of antibiotics. Broad-spectrum antibiotics have long been sold over-the-counter in many former USSR countries, including Ukraine. Patients commonly self-prescribe a round of antibiotics for inappropriate illnesses, such as viral colds. Further, patients may take only a partial course of antibiotics, or local doctors may prescribe prolonged low-dose courses of antibiotics, at below therapeutic dose levels. This stresses bacteria without killing them, and fosters development of AMR bacteria. One large 2020 study found that AMR was present in 25% of hospital infections in Ukraine. Microbes may be Antimicrobial-Resistant (AMR),  Multi-Drug Resistant (MDR) or Extensively-Drug-Resistant (XDR).

Antibiotic overuse is not unique to Ukraine. In the US, for example, the CDC estimates that 5 out of 6 Americans take a course of antibiotics each year, and 1 out of 3 of these treatments are unnecessary. The 2022 Global Antimicrobial Resistance and Use Surveillance System (GLASS) report highlights alarming resistance rates among prevalent bacterial pathogens. Median reported rates in 76 countries of 42% for third-generation cephalosporin-resistant E. coli and 35% for methicillin-resistant Staphylococcus aureus are a major concern. For urinary tract infections caused by E. coli, 1 in 5 cases exhibited reduced susceptibility to standard antibiotics like ampicillin, co-trimoxazole, and fluoroquinolones in 2020. This is making it harder to effectively treat common infections. Klebsiella pneumoniae, a common intestinal bacterium, also showed elevated resistance levels against critical antibiotics. Increased levels of resistance potentially lead to heightened utilization of last-resort drugs like carbapenems, for which resistance is in turn being observed across multiple regions. As the effectiveness of these last-resort drugs is compromised, the risks increase of infections that cannot be treated. Projections by the Organization for Economic Cooperation and Development (OECD) indicate an anticipated twofold surge in resistance to last-resort antibiotics by 2035, compared to 2005 levels, underscoring the urgent need for robust antimicrobial stewardship practices and enhanced surveillance coverage worldwide.

Wartime conditions facilitate the spread of AMR infections in multiple ways. Various strains of AMR bacteria may be acquired in the community, via contaminated food or physical contact with human or animal AMR carriers. Patients may harbor AMR bacteria asymptomatically in the digestive tract or in skin before injury, which is then carried into the wound during the injury event. Infection may also occur during injury, or post-injury, by bacteria in the environment, or from neighboring injured personnel. Bullets and shrapnel wounds allow contaminants deep into the body. Evacuation from the drone-infested frontlines may be impossible to do safely for multiple days. During this time, infection sets in. 

When patient transport and treatment finally occur, staffing and equipment shortages may prevent adequate infection control. For instance, ambulances or ad-hoc casevac vehicles may not have access to equipment needed to fully decon contaminated surfaces, or replace bloody stretchers, etc. If there is only time to address immediate life threats, multi-trauma patients may go through several stages of evacuation with uncovered open wounds. Nurses may be caring for 15-20 patients simultaneously, and lack time or supplies to ensure clean gloves, beds, and equipment are used for every patient contact. Hospitals are overcrowded; for example, patient loads at Dnipro’s Mechnikov Hospital have increased 10-fold during the war, according to Chief Surgeon Sergiy Kosulnikov. Kosulnikov estimates that 50% of his patients developed AMR before ever starting treatment. “Has he been in hospital before? Somewhere else?”, he ponders. The origins of individual AMR infections in the Ukraine war is a key question for public health experts. 

Multi-stage patient care means that patients pass through multiple facilities before discharge, with potential to acquire and spread different strains of AMR bacteria at each facility. Overcrowded facilities cannot afford to isolate AMR patients. Severely injured combat trauma patients are generally immediately started on broad-spectrum antibiotics, because care cannot be delayed several days pending results of drug-susceptibility cultures. While this is in patients’ best interests, it creates opportunities for bacteria to evolve resistance to advanced antibiotics. 

Anecdotal accounts and some science are beginning to emerge on rates of wartime AMR in Ukraine. At the Feofaniya Hospital in Kyiv, for example, more than 80% of recently admitted patients had infections caused by AMR microbes, according to the hospital’s deputy chief physician. “It’s eye-opening just how incredibly resistant some of the bacteria coming out of Ukraine are. I haven’t seen anything like it,” says Jason Bennett, director of the Multidrug-Resistant Organism Repository and Surveillance Network at the Walter Reed Army Institute of Research (WRAIR). A 2023 study by Ukrainian MOH and the US CDC tested 353 Ukrainian patients with hospital-acquired infections in late 2022. They found that 60% were fighting infection resistant to carbapenem antibiotics, which are considered the last resort in treating infections. A German report found a rapid rise in. AMR infections treated in Germany in late 2022, following the influx of refugees and wounded patients from Ukraine.  IN 2023, a Ukrainian burn patient was treated at the US military hospital in Germany. Cultures revealed the presence of six different XDR bacterial strains, which were resistant to nearly all known antibiotics. 

Ukraine is not the first war to foster AMR. Acinetobacter baumannii, or “Iraqibacter”, evolved during the Iraq war, and went on to cause 19% of European ventilator-associated pneumonia cases by 2009.

If the Ukraine war has a “signature bacteria”, it is probably Klebsiella pneumoniae. This organism is already responsible for 20% of AMR deaths worldwide. A unique feature of Klebsiella is the copious mucous it produces, which allows AMR Klebsiella colonies on the surface of the wound to act as a biofilm, shielding susceptible bacteria deeper in the wound. Cultures from Ukrainian casualties have contained hyper-virulent, pan-drug resistant strains of K. pneumoniae (i.e. only treatable with a sophisticated multi-drug cocktail).

AMR prevention: Local measures. Good infection control measures are crucial to preventing spread of AMR in hospitals and on ambulances. 

Gloves should be changed between patients

Provide handwashing facilities and encourage frequent use by providers and patients

All commonly touched ambulance surfaces should be cleaned with hospital-grade disinfectant after every transport. Patient treatment areas in-facility should be cleaned thoroughly between patients. Ensure the cleaning agent has enough contact time (see bottle, or ~1-2min on the surface before drying occurs). 

Fully decontaminate or replace all instruments and patient care equipment between patients (including trauma shears, BVMs, etc)

Keep a fresh, clean sheet or mylar foil blanket on stretchers and hospital beds

Irrigate away gross wound contamination with sterile fluids as early as possible in stable patients (but do not risk causing hypothermia to do so)

If time allows, cut away patient clothing to remove as many gross contamination sources as possible, before pt transfer from ambo stretcher onto a facility bed

Cover open wounds, when possible, with CLEAN dressings. Be careful not to cross-contaminate multi-packs of dressings and other materials.

Avoid unnecessary dressing changes during interfacility transports

Nationally, Ukraine is making efforts to reduce AMR spread. In 2022, Ukraine ceased over-the-counter sales of antibiotics. A prescription is now required. 

On an international level, the US CDC and ICAP are working to strengthen AMR surveillance, prevention, and treatment in three Ukrainian pilot hospitals and labs. These are large regional facilities in Vinnytsia, Ternopil, and Khmelnytskyi. The selected hospitals “are dealing with the equivalent of a mass casualty event on a weekly basis because there are so many people getting injured,” said ICAP’s regional AMR advisor. The project also supports the national reference lab at the Ukrainian Public Health Center. 

By Sept 2024, Ukraine had 100 labs carrying out surveillance for AMR bacteria, as compared to just 3 in 2017. Yet, no systematic data collection for wound infections yet exists in Ukraine. The University of Colorado School of Medicine was recently awarded a $5million US DOD grant to create such infrastructure. This project is called the ARROW (Antimicrobial Resistance Research to Improve Outcomes of Traumatic Wounds) study. 

BBC Newstory: Dangerous Drug-Resistant Bacteria are Spreading in Ukraine

WHO: AMR Could Surpass Cancer as the Leading Cause of Death by 2050

Science: War-torn Ukraine has become a breeding ground for lethal drug-resistant bacteria

Ukraine: Blast Injuries

Blast Physics

Modern close-combat drones in the Ukraine war are modified to carry a multitude of different explosive charges. This can range from a simple VOG or RGD-5 grenades (34g of A-IX-1 explosive, or 110g TNT, respectively), to “petal” and PMN-2 antipersonnel mines (37g VS-6D explosive, or 100g TG-40, respectively), to anti-tank mines (typically with several kg of high explosive).

High-Order explosives create supersonic blast waves (C-4, semtex, dynamite, ammonium nitrate, TNT, etc). These are commonly found in conventional military weapons.

Low-Order explosives create subsonic blast waves and less shear velocity (molotov cocktails, gunpowder, pipe bombs, etc). Damage may be severe, due to involvement of fragments, hot gases, and infectious agents. These are typically used in improvised, non-military-grade weapons.

Blasts produce two basic types of pressure waves:

Stress waves are supersonic, longitudinal pressure waves with high potential for injury, especially of gas-filled organs

Shear waves are lower velocity, longer duration transverse waves, which cause tissue in the body to move back and forth. 

Understanding the Mechanisms of Injury in Blasts

Blast injury patterns are complex and unpredictable. Important variables include type of explosive device, patient proximity to the blast, soil conditions, and whether the event occurred in a closed space.

As a broad rule, casualties with traumatic amputations from conventional explosives were usually within ~1 meter of the device. These account for a large proportion of the immediate fatalities. Assume any patient with a limb amputation also has multi-system injuries.

Explosions causing shattering glass have a high incidence of penetrating eye injuries, which may initially be occult. Most eye injuries are preventable with simple eye protection. 

In the case of ground explosions from mine and incoming artillery/missiles, soil conditions have a huge affect on the amount of blast energy that is delivered‬ to the victim. During detonation, an expanding sphere‬ of hot gas drives a shock wave ahead of it. Dry, loose sand‬ allows this sphere and shockwave to dissipate downwards‬ into the ground, as well as upwards. If the ground is frozen,‬ hard, packed earth or saturated clay, energy is reflected‬ upwards, amplifying the damage done to the victim.

Those with primary (blast wave) injuries are most often survivors of closed-space explosions. Primary blast injuries typically result from three different physical mechanisms: spallation, implosion, and shearing injuries. Spallation occurs when the pressure blast wave passes from a dense medium to a less dense medium (e.g., bowel wall into the gas-filled bowel). Implosion results from compression of tissue that is otherwise not typically compressible (e.g., solid organs). Shearing results from acceleration/deceleration, which displaces the tissue, causing tearing injuries.

Lung injuries occur at pressure increases over 40 psi. Pressure increases over 200psi in open air are almost universally fatal. Lung injuries are the most common cause of death due to primary blast effect. Signs and symptoms may be immediate, or delayed for up to 48 hours.

Ear injuries can occur from as little as 5-15psi of overpressure. Therefore these injuries may occur in open-air settings, or in patients that were not immediately adjacent to the device. Absence of tympanic rupture (symptoms are noticeable loss of hearing + some blood in ear canals) can help rule out other higher-pressure injuries. Hearing loss may be temporary or permanent. 

The category of “Quinary Blast Injury” (clinical consequences of post-detonation environmental contaminants, including chemical (e.g., sarin), biological (e.g., anthrax), and radiological (e.g., dirty bombs) substances) has recently come into common use

Briefs on Common Blast Injuries

Lung Injury

“Blast lung” is a direct consequence of the HE over-pressurization wave. It is the most common

fatal primary blast injury among initial survivors. Signs of blast lung are usually present at the

time of initial evaluation, but they have been reported as late as 48 hours after the explosion.

Blast lung is characterized by the clinical triad of apnea, bradycardia, and hypotension.

Pulmonary injuries vary from scattered petechae to confluent hemorrhages. Blast lung should

be suspected for anyone with dyspnea, cough, hemoptysis, or chest pain following blast

exposure. Blast lung produces a characteristic “butterfly” pattern on chest X-ray. 

Ear Injury

Primary blast injuries of the auditory system cause significant morbidity, but are easily

overlooked. Injury is dependent on the orientation of the ear to the blast. TM perforation

is the most common injury to the middle ear. Signs of ear injury are usually present at

time of initial evaluation and should be suspected for anyone presenting with hearing loss,

tinnitus, otalgia, vertigo, bleeding from the external canal, TM rupture, or mucopurulent

otorhea. All patients exposed to blast should have an otologic assessment and audiometry.

Abdominal Injury

Gas-containing sections of the GI tract are most vulnerable to primary blast effect. This

can cause immediate bowel perforation, hemorrhage (ranging from small petechiae to

large hematomas), mesenteric shear injuries, solid organ lacerations, and testicular

rupture. Blast abdominal injury should be suspected in anyone exposed to an explosion

with abdominal pain, nausea, vomiting, hematemesis, rectal pain, tenesmus, testicular

pain, unexplained hypovolemia, or any findings suggestive of an acute abdomen. Clinical

findings may be absent until the onset of complications (peritonitis, sepsis).

Brain Injury

Primary blast waves can cause concussions or mild traumatic brain injury (MTBI)

without a direct blow to the head. Consider the proximity of the victim to the blast

particularly when given complaints of headache, fatigue, poor concentration, lethargy,

depression, anxiety, insomnia, or other constitutional symptoms. The symptoms of

concussion and post traumatic stress disorder can be similar

            US Marine Corps guide to Blast-Relared Injuries

             American Journal of Emergency Medicine: Blast Injuries

*** Tables and selected text excepts above and below from: CDC Blast Injuries Fact Sheet

Geneva Convention, Part Two: Protections for Hospitals and Medical Providers

 

The text of the First Convention, as revised by the 1949 Conference, follows traditional lines and the fundamental principles that governed former versions: wounded or sick – and therefore defenceless – combatants shall be respected and cared for, whatever their nationality; personnel attending them, the buildings in which they shelter and the equipment used for their benefit, shall be protected; a red cross on a white ground shall be the emblem of this immunity

Russia, Ukraine, the US, and most European countries are all signatories to the Geneva Convention.

As of Sept 2024, WHO has confirmed close to 2000 attacks on health in Ukraine, including on hospitals, health workers and patients.

International Humanitarian Law concerning hospitals can be summed up as: 

“hospitals, ambulances, and medical providers (military OR civilian) are protected, unless they are used for acts that are considered “harmful to the enemy”

 Geneva Convention Key Points, Concerning Hospitals, Ambulances, and Medics

Both sides in a conflict are obligated to collect and care for the wounded, including enemy wounded

The following are protected against murder, torture, and degrading treatment:

Wounded noncombatants (journalists, civilians, supply contractors, etc),

Wounded combatants (regular military, organized, uniformed militia, and local residents who spontaneously resist invasion) who have laid down their arms 

The following are protected from attack:

Hospitals

Ambulances

Medical personnel (military, NGO, and civilian)

Military personnel with auxiliary medical training (this only applies while actively performing solely medical duties such as nursing or stretcher-bearing) 

The protection to which fixed establishments and mobile medical units of the Medical Service are entitled shall not cease unless they are used to commit, outside their humanitarian duties, acts harmful to the enemy. The following acts DO NOT cause medical facilities to lose protections:

Carrying arms or using them in their own defense, or in defense of patients

Using armed sentries or armed escorts

Temporary storage of small arms and ammunition taken from the wounded

Medical personnel exclusively engaged in the search for, or the collection, transport or treatment of the wounded or sick shall be respected and protected in all circumstances.

Members of the armed forces specially trained for employment, should the need arise, as hospital orderlies, nurses or auxiliary stretcher-bearers, in the transport or treatment of the wounded shall be respected and protected if they are carrying out these duties at the time when they come into contact with the enemy.

Geneva Convention, Full Relevant Text, Concerning Hospitals, Ambulances, and Medics 

*** All below text in quotations is taken directly from the original GENEVA CONVENTION FOR THE AMELIORATION OF THE CONDITION OF THE WOUNDED AND SICK IN ARMED FORCES IN THE FIELD OF 12 AUGUST 1949 document; non-relevant portions are omitted for brevity. Full text available here: https://www.icrc.org/sites/default/files/external/doc/en/assets/files/publications/icrc-002-0173.pdf***

1) Persons taking no active part in the hostilities, including members of armed forces who have laid down their arms and those placed hors de combat by sickness, wounds, detention, or any other cause, shall in all circumstances be treated humanely, without any adverse distinction founded on race, colour, religion or faith, sex, birth or wealth, or any other similar criteria. To this end, the following acts are and shall remain prohibited at any time and in any place whatsoever with respect to the above-mentioned persons: 

a) violence to life and person, in particular murder of all kinds, mutilation, cruel treatment and torture; 

b) taking of hostages; 

c) outrages upon personal dignity, in particular humiliating and degrading treatment; 

d) the passing of sentences and the carrying out of executions without previous judgment pronounced by a regularly constituted court, affording all the judicial guarantees which are recognized as indispensable by civilized peoples. 

2) The wounded and sick shall be collected and cared for

(1949 Geneva Convention, Article 3)

The High Contracting Parties may at any time agree to entrust to an organization which offers all guarantees of impartiality and efficacy the duties incumbent on the Protecting Powers by virtue of the present Convention

When wounded and sick, or medical personnel and chaplains do not benefit or cease to benefit, no matter for what reason, by the activities of a Protecting Power or of an organization provided for in the first paragraph above, the Detaining Power shall request a neutral State, or such an organization, to undertake the functions performed under the present Convention by a Protecting Power designated by the Parties to a conflict.

If protection cannot be arranged accordingly, the Detaining Power shall request or shall accept, subject to the provisions of this Article, the offer of the services of a humanitarian organization, such as the International Committee of the Red Cross, to assume the humanitarian functions performed by Protecting Powers under the present Convention….

Whenever in the present Convention mention is made of a Protecting Power, such mention also applies to substitute organizations in the sense of the present Article.

(1949 Geneva Convention, Article 10)

Members of the armed forces and other persons mentioned in the following Article, who are wounded or sick, shall be respected and protected in all circumstances. They shall be treated humanely and cared for by the Party to the conflict in whose power they may be, without any adverse distinction founded on sex, race, nationality, religion, political opinions, or any other similar criteria. Any attempts upon their lives, or violence to their persons, shall be strictly prohibited; in particular, they shall not be murdered or exterminated, subjected to torture or to biological experiments; they shall not wilfully be left without medical assistance and care, nor shall conditions exposing them to contagion or infection be created. Only urgent medical reasons will authorize priority in the order of treatment to be administered. Women shall be treated with all consideration due to their sex. The Party to the conflict which is compelled to abandon wounded or sick to the enemy shall, as far as military considerations permit, leave with them a part of its medical personnel and material to assist in their care.

(1949 Geneva Convention, Article 12)

The Present Convention shall apply to the wounded and sick belonging to the following categories: 

1) Members of the armed forces of a Party to the conflict as well as members of militias or volunteer corps forming part of such armed forces. 

2) Members of other militias and members of other volunteer corps, including those of organized resistance movements, belonging to a Party to the conflict and operating in or outside their own territory, even if this territory is occupied, provided that such militias or volunteer corps, including such organized resistance movements, fulfil the following conditions: 

a) that of being commanded by a person responsible for his subordinates; 

b) that of having a fixed distinctive sign recognizable at a distance; 

c) that of carrying arms openly; 

d) that of conducting their operations in accordance with the laws and customs of war. 

3) Members of regular armed forces who profess allegiance to a Government or an authority not recognized by the Detaining Power.

4) Persons who accompany the armed forces without actually being members thereof, such as civilian members of military aircraft crews, war correspondents, supply contractors, members of labour units or of services responsible for the welfare of the armed forces, provided that they have received authorization from the armed forces which they accompany. 

5) Members of crews including masters, pilots and apprentices of the merchant marine and the crews of civil aircraft of the Parties to the conflict, who do not benefit by more favourable treatment under any other provisions in international law. 

6) Inhabitants of a non-occupied territory who, on the approach of the enemy, spontaneously take up arms to resist the invading forces, without having had time to form themselves into regular armed units, provided they carry arms openly and respect the laws and customs of war.

(1949 Geneva Convention, Article 13)

At all times, and particularly after an engagement, Parties to the conflict shall, without delay, take all possible measures to search for and collect the wounded and sick, to protect them against pillage and ill-treatment, to ensure their adequate care, and to search for the dead and prevent their being despoiled. Whenever circumstances permit, an armistice or a suspension of fire shall be arranged, or local arrangements made, to permit the removal, exchange and transport of the wounded left on the battlefield. Likewise, local arrangements may be concluded between Parties to the conflict for the removal or exchange of wounded and sick from a besieged or encircled area, and for the passage of medical and religious personnel and equipment on their way to that area. 

(1949 Geneva Convention, Article 15)

The military authorities may appeal to the charity of the inhabitants voluntarily to collect and care for, under their direction, the wounded and sick, granting persons who have responded to this appeal the necessary protection and facilities. Should the adverse Party take or retake control of the area, it shall likewise grant these persons the same protection and the same facilities. The military authorities shall permit the inhabitants and relief societies, even in invaded or occupied areas, spontaneously to collect and care for wounded or sick of whatever nationality. The civilian population shall respect these wounded and sick, and in particular abstain from offering them violence. No one may ever be molested or convicted for having nursed the wounded or sick. The provisions of the present Article do not relieve the occupying Power of its obligation to give both physical and moral care to the wounded and sick.

(1949 Geneva Convention, Article 18)

Fixed establishments and mobile medical units of the Medical Service may in no circumstances be attacked, but shall at all times be respected and protected by the Parties to the conflict. Should they fall into the hands of the adverse Party, their personnel shall be free to pursue their duties, as long as the capturing Power has not itself ensured the necessary care of the wounded and sick found in such establishments and units. The responsible authorities shall ensure that the said medical establishments and units are, as far as possible, situated in such a manner that attacks against military objectives cannot imperil their safety

(1949 Geneva Convention, Article 19)

The protection to which fixed establishments and mobile medical units of the Medical Service are entitled shall not cease unless they are used to commit, outside their humanitarian duties, acts harmful to the enemy. Protection may, however, cease only after a due warning has been given, naming, in all appropriate cases, a reasonable time limit and after such warning has remained unheeded.

(1949 Geneva Convention, Article 21)

The following conditions shall not be considered as depriving a medical unit or establishment of the protection guaranteed by Article 19: 

1. That the personnel of the unit or establishment are armed, and that they use the arms in their own defence, or in that of the wounded and sick in their charge. 

2. That in the absence of armed orderlies, the unit or establishment is protected by a picket or by sentries or by an escort. 

3. That small arms and ammunition taken from the wounded and sick and not yet handed to the proper service, are found in the unit or establishment. 

4. That personnel and material of the veterinary service are found in the unit or establishment, without forming an integral part thereof. 

5. That the humanitarian activities of medical units and establishments or of their personnel extend to the care of civilian wounded or sick. 

(1949 Geneva Convention, Article 22)

Protection of permanent personnel: 

Medical personnel exclusively engaged in the search for, or the collection, transport or treatment of the wounded or sick, or in the prevention of disease, staff exclusively engaged in the administration of medical units and establishments, as well as chaplains attached to the armed forces, shall be respected and protected in all circumstances.

(1949 Geneva Convention, Article 24)

Protection of auxiliary personnel: 

Members of the armed forces specially trained for employment, should the need arise, as hospital orderlies, nurses or auxiliary stretcher-bearers, in the search for or the collection, transport or treatment of the wounded and sick shall likewise be respected and protected if they are carrying out these duties at the time when they come into contact with the enemy or fall into his hands.

(1949 Geneva Convention, Article 25)

Personnel of aid societies:

The staff of National Red Cross Societies and that of other Voluntary Aid Societies, duly recognized and authorized by their Governments, who may be employed on the same duties as the personnel named in Article 24, are placed on the same footing as the personnel named in the said Article, provided that the staff of such societies are subject to military laws and regulations. 

Each High Contracting Party shall notify to the other, either in time of peace or at the commencement of or during hostilities, but in any case before actually employing them, the names of the societies which it has authorized, under its responsibility, to render assistance to the regular medical service of its armed forces.

(1949 Geneva Convention, Article 26)

Personnel designated in Articles 24 and 26 who fall into the hands of the adverse Party, shall be retained only in so far as the state of health, the spiritual needs and the number of prisoners of war require. Personnel thus retained shall not be deemed prisoners of war. Nevertheless they shall at least benefit by all the provisions of the Geneva Convention relative to the Treatment of Prisoners of War of August 12, 1949. Within the framework of the military laws and regulations of the Detaining Power, and under the authority of its competent service, they shall continue to carry out, in accordance with their professional ethics, their medical and spiritual duties on behalf of prisoners of war, preferably those of the armed forces to which they themselves belong. They shall further enjoy the following facilities for carrying out their medical or spiritual duties: a) They shall be authorized to visit periodically the prisoners of war in labour units or hospitals outside the camp. The Detaining Power shall put at their disposal the means of transport required. b) In each camp the senior medical officer of the highest rank shall be responsible to the military authorities of the camp for the professional activity of the retained medical personnel. For this purpose, from the outbreak of hostilities, the Parties to the conflict shall agree regarding the corresponding seniority of the ranks of their medical personnel, including those of the societies designated in Article 26.In all questions arising out of their duties, this medical officer, and the chaplains, shall have direct access to the military and medical authorities of the camp who shall grant them the facilities they may require for correspondence relating to these questions. c) Although retained personnel in a camp shall be subject to its internal discipline, they shall not, however, be required to perform any work outside their medical or religious duties…

(1949 Geneva Convention, Article 28)

The real and personal property of aid societies which are admitted to the privileges of the Convention shall be regarded as private property. The right of requisition recognized for belligerents by the laws and customs of war shall not be exercised except in case of urgent necessity, and only after the welfare of the wounded and sick has been ensured.

(1949 Geneva Convention, Article 34)

Transports of wounded and sick or of medical equipment shall be respected and protected in the same way as mobile medical units. Should such transports or vehicles fall into the hands of the adverse Party, they shall be subject to the laws of war, on condition that the Party to the conflict who captures them shall in all cases ensure the care of the wounded and sick they contain…

(1949 Geneva Convention, Article 35)

Medical aircraft, that is to say, aircraft exclusively employed for the removal of wounded and sick and for the transport of medical personnel and equipment, shall not be attacked… They shall bear, clearly marked, the distinctive emblem prescribed in Article 38, together with their national colours, on their lower, upper and lateral surfaces…

(1949 Geneva Convention, Article 36)

Under the direction of the competent military authority, the [Red Cross/Crescent/Diamond] emblem shall be displayed on the flags, armlets and on all equipment employed in the Medical Service.

(1949 Geneva Convention, Article 36)

The personnel designated in Article 24 and in Articles 26 and 27 shall wear, affixed to the left arm, a water-resistant armlet bearing the distinctive emblem, issued and stamped by the military authority. Such personnel, in addition to wearing the identity disc mentioned in Article 16, shall also carry a special identity card bearing the distinctive emblem…

(1949 Geneva Convention, Article 40)

The distinctive flag of the Convention shall be hoisted only over such medical units and establishments as are entitled to be respected under the Convention, and only with the consent of the military authorities. In mobile units, as in fixed establishments, it may be accompanied by the national flag of the Party to the conflict to which the unit or establishment belongs. Nevertheless, medical units which have fallen into the hands of the enemy shall not fly any flag other than that of the Convention. Parties to the conflict shall take the necessary steps, in so far as military considerations permit, to make the distinctive emblems indicating medical units and establishments clearly visible to the enemy land, air or naval forces, in order to obviate the possibility of any hostile action.

(1949 Geneva Convention, Article 42)

The High Contracting Parties undertake to enact any legislation necessary to provide effective penal sanctions for persons committing, or ordering to be committed, any of the grave breaches of the present Convention defined in the following Article. Each High Contracting Party shall be under the obligation to search for persons alleged to have committed, or to have ordered to be committed, such grave breaches, and shall bring such persons, regardless of their nationality, before its own courts…

(1949 Geneva Convention, Article 49)

Grave breaches to which the preceding Article relates shall be those involving any of the following acts, if committed against persons or property protected by the Convention: wilful killing, torture or inhuman treatment, including biological experiments, wilfully causing great suffering or serious injury to body or health, and extensive destruction and appropriation of property, not justified by military necessity and carried out unlawfully and wantonly.

(1949 Geneva Convention, Article 50)

The use by individuals, societies, firms or companies either public or private, other than those entitled thereto under the present Convention, of the emblem or the designation “Red Cross” or “Geneva Cross”, or any sign or designation constituting an imitation thereof, whatever the object of such use, and irrespective of the date of its adoption, shall be prohibited at all times…

(1949 Geneva Convention, Article 53)

*** All below text in quotations is taken directly from the original GENEVA CONVENTION RELATIVE TO THE PROTECTION OF CIVILIAN PERSONS IN TIME OF WAR OF 12 AUGUST 1949 document; non-relevant portions are omitted for brevity. Full text available here: https://www.icrc.org/sites/default/files/external/doc/en/assets/files/publications/icrc-002-0173.pdf***

Persons protected by the Convention are those who at a given moment and in any manner whatsoever, find themselves, in case of a conflict or occupation, in the hands of persons a Party to the conflict or Occupying Power of which they are not nationals. Nationals of a State which is not bound by the Convention are not protected by it. Nationals of a neutral State who find themselves in the territory of a belligerent State, and nationals of a co-belligerent State, shall not be regarded as protected persons while the State of which they are nationals has normal diplomatic representation in the State in whose hands they are.

(1949 Geneva Convention Relative to Protection of Civilian Persons in Time of War, Article 4)

Links

          Geneva Convention, full text relating to Hospitals 

           International Committee of the Red Cross Website

           Doctors Without Borders’ Practical Guide to Humanitarian Law