Ukraine: Looking back at Simon Ostrosky's Vice News Reporting on the 2014 DNR Takeover of Sloviansk

 

The full series is available on Youtube: Vice News: Russian Roulette

Ukraine: Wound Packing and Tourniquet Conversion Example

 The first conversion attempt was unsuccessful. After use of xstat, the second conversion attempt was successful!  -3rd brigade, 2nd mech

Ukraine: Refugees

 

EU Blocks Telegram Channels that Disseminate Russian Propaganda

MSN: Telegram blocks Russian State-Owned Media Channels in several EU Countries 

Fatalities from Armed Conflict: Three-Decade Trend (includes civilian and military)

Ukraine: Frostbite and Trench Foot Prevention and Treatment

 FROSTBITE AND TRENCH FOOT

Frostbite is injury due to formation of ice crystals within tissues. Adjacent tissues may be damaged by vasoconstriction, thrombosis, and inflammation, 

Determining the severity of a cold injury can be challenging during early phases. Initial signs and symptoms in severe frostbite may appear deceptively benign; conversely, mild cold injuries such as frostnip may present similarly to frostbite.

Prior to rewarming, frostbitten tissues are cold, white, hard, numb, and sometimes blistered. After rewarming, skin becomes blotchy red, swollen, and extremely painful. Blisters tend to appear within 4-6 hours of rewarming. Clear, serum-filled blisters indicate superficial damage, without residual tissue loss. Blood-filled blisters accompany deep tissue damage and likely tissue loss. Longer-term complications can include compartment syndrome, gangrene (usually dry, with a hard black carapace over healthy tissue), need for amputation, and long-term neuropathic symptoms. The full extent of frostbite damage may take several days to several weeks to become clear.

TCCC has four frostbite categories:

First Degree (Superficial): Superficial skin injury, pain on rewarming, numbness, hyperemia, occasionally blue mottling, swelling and superficial desquamation (after ~5 days)

Second Degree (Superficial): Partial thickness injury to skin, in addition to first degree findings, vesiculation of the skin surrounded by erythema and edema (appears around day 2)

Third Degree (Full Thickness): Entire thickness of skin extending into subcutaneous tissue, bluish to black and non-deformable skin, hemorrhagic blisters, vesicles may not be present, eventual ulcerations can be expected, area will likely be surrounded by 1st or 2nd degree injury

Fourth Degree (Full Thickness): Similar to third degree, but full thickness damage including bone. Area may be cold to touch and may feel stiff or woody.

Immersion Foot: Caused by prolonged exposure to moisture. Feet, especially soles, become water-logged, hyperemic, mottled, painful, and edematous, gradually progressing to blistering, hypoperfusion, ulceration, and gangrene if untreated. Treatment is re-warming and drying at room temperature. Pain control and debridement may be required. As with other cold injuries, persistent life-altering symptoms may occur. 

TCCC frostbite treatment protocols are as follows: 

***Treatment protocols in Ukraine will depend on local guidelines*** 

Address major trauma and hypothermia before focusing on frostbitten extremities. 

PREVENTION in patients: Ukraine conflict conditions and injury patterns can predispose patients to cold injuries, in several ways.

Field conditions: Immediately post-injury, it may be necessary to prioritize movement, cover, and returning fire over keeping patients dry and fixing damaged winter clothing systems. In Ukraine at present, Casualty Collection Point and/or field care is generally provided by personnel with auxiliary training, only at the Combat Lifesaver / EMT-Basic level. Due to large numbers of patients, and pervasive drone, artillery, and direct-fire threats, it is common for this Care Under Fire / Tactical Field Care phase to be extremely prolonged. Patients typically spend 6 - 48 hours, or more, on position prior to casevac. 

Nature of Injuries and Medical Interventions: Patients’ mobility, and their ability to protect their own limbs, may be reduced due to injuries and altered mental status (from medication or trauma). Circulation to limbs may be further impaired due to direct trauma, hypotension, shock, global hypothermia, and bleeding control measures. During early care phases, global hypothermia prevention is much more effective against cold injuries than localized hypothermia prevention. Hypothermia is particularly dangerous in trauma patients, as it combines with coagulopathy and acidosis to form a positive feedback loop (“the Lethal Triad”). Climate control systems may be inadequate or absent in transport vehicles and treatment areas (ideally you should be uncomfortably warm in the room where you treat a trauma patient). Preheat chemical blankets, and turn up the heat in the patient compartment while enroute to the AXP. Minimize opening doors and patient transfer time into the ambulance. Even the best care teams may allow a patient to become hypothermic while focused on performing advanced procedures. Remove clothing and blankets from the patient only long enough to perform essential exams and medical interventions. Consider using multiple blankets to “burrito wrap” the patient.

TREATMENT: Hospital / Prolonged Field Care Phase: The core of frostbite treatment is rapidly rewarming the frostbitten area in warm water (37-40 degrees celsius)  This should take 15-30 min if water is kept continuously at 37-40. (TCCC calls for 40-42 degree water; however recent studies have shown this causes additional pain without improving outcomes). The longer the tissue remains frozen, the greater the damage. A general rule of thumb is that if the patient cannot reach a hospital in the next two hours, field rewarming should be undertaken. However, NEVER THAW tissue unless it can be guaranteed that it will not re-freeze. Do not thaw feet if the patient will have to walk on them in the near future; thawed tissue is delicate and susceptible to trauma. Dry heat sources should be avoided; they may burn numb tissue. Avoid the temptation to prematurely end rewarming due to pain; rapid rewarming is more painful but produces better outcomes than slow rewarming. Liberal use of pain medication is highly encouraged during the rewarming process. The patient should move the affected part gently during rewarming.  Do not rub affected areas, or apply snow or oil. Leave blisters intact to prevent infection and deep tissue dessication. Preventing infection is paramount. The hospital may use vasodilators, anticlotting meds, NSAIDs, and elevation to encourage reperfusion.  Patients should avoid vasoconstrictors such as nicotine, and be monitored for electrolyte abnormalities. Acute, persistent pain will generally subside within the first three days, although intermittent nerve pain may continue for an extended period.

Previous Medical Spotlights

Blood Loss and the Lethal Triad

TB and the Ukraine War

Ketamine in War, Including Use in TBI Patients

Crush Injury and Compartment Syndrome

Frostbite

Joke: A Ukrainian Man Goes Before Saint Peter:

Saint Peter asks 'Where were you born?'

The man thinks for a moment and says 'Austria-Hungary, Lemberg.'

'Where did you go to school?'

'Poland, Lwow.'

'Where were you married?'

'The Ukrainian S.S.R., Lviv.'

Surprised, Saint Peter asks 'Where was your first child born?'

'In the German Reich.'

'And where did you die?'

'At home in Lvov, in the Soviet Union.'

Astonished, Saint Peter shouts 'My, you moved around a lot!'

'What are you talking about? I never left the city!'

Ukrainian Musician Plays Shedruk (Carol of the Bells) on a Traditional Bandura, Near the Front Line at Pokrovsk

 

Ukraine: Human Rights Watch Report Summary on Torture of Civilians by Russian Military in Izium

Human Rights Watch Investigators visited Izium in the fall of 2022, after the city was liberated by the Ukrainian counter-offensive. Multiple civilian residents describe being detained and tortured by Russian soldiers in the report.

NEWS ARTICLE: Human Rights Watch Report Summary on Torture of Civilians by Russian Military in Izium

Downing Drones with Radio Waves

 This British Ministry of Defense reports successful testing of its RFDEW. This platform can shoot down drones up to a kilometer away, using radio waves, at the cost of 10 pence per shot.

Ukraine: Incoming Artillery in Donbas

 

 

Ukraine: One of the Longest Armored Movements Behind Enemy Lines in History: The Raid of the 95th Brigade (2014)

 

During the Donbas War, elements of the Ukrainian Army reportedly made a 170km dash behind enemy lines, in order to resupply a cut-off unit. According to Potomoc Institute for Policy Studies historian, Dr, Philip Karber, this was one of the longest armored raids in history.  

Between 19 July and 10 August, units of the Ukrainian 95th Air Assault Brigade, reinforced with elements of the 25th Airborne and 30th and 51st Mechanized Brigades, conducted a 470 km raid, of which 170km was behind Russian and Separatist lines. All those who took part in the operation on the Ukrainian side were volunteers. The raid was successful, allowing for the creation of a safety corridor to evacuate Ukrainian units trapped behind enemy lines at the Russia-Ukraine border. 3,000 troops and over 250 pieces of equipment of the 24th, 72nd Mechanized, and 79th Air Assault Brigades. 

This was the first direct clash between Ukrainian and Russian troops of the Donbas War. The soldiers involved have been praised by military experts and historians for the skill and daring that went into the raid. 

Watch a youtube video from Battle Order, about the raid:

Volunteer Group Platsdarm is bringing fallen soldiers home, from both sides of the Ukraine Conflict

 Oleksii Yukov's volunteer group, Platsdarm, has been working in Eastern Ukraine since 2014. In this time, it has conducted respectful recovery of the remains of over 2,000 fallen soldiers, and returned them to their families in Ukraine and Russia. This provides crucial closure for families of those who went missing in the conflict. Prior to the Donbas war, Mr Yukov worked with groups that recovered remains of soldiers lost in WWI and WWII. 

Link to Voice of America video story on Platsdam:

Ukraine: Christmas Memorial Installation in Kiev

Christmas dinner table with empty chairs and soldiers' uniforms commemorates those who are dead or missing

 

Ukraine: Christmas Message from Dr. John Quinn

"To All of You and cross posting:

You are doing extraordinary work. Keep it up. We face gaps, challenges, and immense headwinds. It is critical that we keep our focus aligned on one shared mission: to reduce preventable morbidity and mortality among the Ukrainian warfighter, the volunteer warfighter, and all volunteers and medical support elements across the FLOT.

We all know the stakes. If we lose focus, people die. People are injured. Projects stall. Partnerships falter. And ultimately, we may lose. The fragmentation I’m seeing as I depart is a direct result of the enemy’s efforts to divide us. Do not let this happen.

Engage. Partner. Support. Do what you do best, what you know is right, and what is needed—always. If in doubt, ask for forgiveness, not permission.

Despite the challenges—financial, relational, and operational—you must persist. Do not give up. Do not surrender. Do not let the enemy win.

Wishing you all a Merry Christmas (whichever one you celebrate), Happy Hanukkah, and Happy Holidays. Stay strong, stay united, and stay focused.

With respect and gratitude, Slava Ukraine! -Quinn"

 -Message from Dr. John Quinn, an American physician who has been going to Ukraine since the start of the Donbas War. He has been instrumental in approval of blood products for prehospital use in Ukraine

Ukraine: Eliminating Enemy Surveillance drones and Shaheds

Over four months in 2024, drones of the 3rd Assault Division aerial defense units brought down dozens of Russian Lancet, Orlan, Zala, Supercam, and other drones. 

Paths of Russian aerial attack assets on 28 Nov 2024. Yellow triangles indicated Shahed drones, other colors are missiles.

 

 

Ukraine: Medical Evacuation Under Fire

 

Ketamine in War, including use in TBI patients

Fast-acting, easy to deliver, and respiratory-drive-sparing, ketamine is becoming an increasingly popular solution for pain control and/or sedation in emergency and combat medicine.

Traditional anesthetic and analgesic medications pose several challenges during wartime conditions. Opiates and benzodiazepines come with side effects, such as hypotension and respiratory depression, which can increase patient-management workload.

In 1958, the search for a safer anesthesia agent yielded PCP. However, severe psychological recovery effects quickly ruled out high-dose PCP as an anesthetic (non-schizophrenic patients tended to experience 1-2 days of artificially-induced withdrawal psychosis, while in schizophrenics existing symptoms were profoundly exacerbated).

200 derivatives of PCP underwent further testing. One of these, ketamine, was found to have a short duration of action and produce less stimulant effects than PCP. Ketamine could be delivered by multiple routes (IV, IM, IN) and spared patients' breathing and airway protection reflexes. Ketamine was first synthesized in 1962, and after testing on animals and volunteer prisoners, was approved for use in humans in 1970.

For many decades, concerns over misuse and hallucinogenic side effects discouraged use of ketamine in mainstream medical practice. However, the drug was used with some success in a number of conflicts during the 70's and 80's. Ketamine's first wartime use was by a composite team of UK, French, and US doctors during the 1970 Jordan-PLO civil war. This team used ketamine to sedate children during treatment of burns. IM administration simplified delivery, and having a sedation option with minimal airway impact freed up caregivers in a resource-poor setting. 

Another early use of ketamine was during the Falklands conflict. Fifty burn patients were given ketamine during wound treatment on the Hospital ship Uganda. The patients came in in a wave of 150 casualties, after the bombing of two landing ships.

By the late 90's and early 2000's, research had disproved many misconceptions surrounding

ketamine. Emerging as one of the safest and most versatile battlefield medicines, the drug

saw renewed interest from the US military and from EMS systems. Various US special

operations teams added ketamine to their protocols during the Afghanistan and Iraq wars. In

2012, the US Defense Health Board added ketamine to TCCC protocols as a primary pain

control option (50mg IN or IM, of a 20mg slow IV/IO push). Various military studies from

this period suggest that ketamine administration had either a neutral or protective action against development of PTSD in injured soldiers.

Use of ketamine for pain control is an off-label use; however it seems to be a highly effective alternative to opiates. Ketamine antagonizes NMDA receptors. It interferes with the brain's chemical ability to receive incoming pain stimuli, and at the same time reduces the emotional reaction to pain. Pain control is achieved at a fraction of an anesthesia dose.

Several other factors make ketamine an ideal pain control+ sedation option in EMS,

wilderness medicine, and combat situations. Rather than dropping respiratory drive and

blood pressure, like opiates and benzodiapines ketamine produces hyper-adrenergic effects.

It stimulates the release of dopamine, norepinephrine, and serotonin, and blocks re-uptake of catecholamines. This leads to a slight increase in blood pressure and heartrate. Additional

benefits include a long shelf life, a wide storage temperature tolerance, low cost, good safety profile, ability to administer via IN, IM, IV or IO route, fast action onset, and a variety of dose-dependent effects. Recent studies have dismissed concerns about use of ketamine in TBI patients, showing that the drug does not have a negative impact on cranial perfusion pressure. Ketamine is recommended by the Wilderness Medical Society for use in remote environments, and is on the WHO essential medications list. In resource-poor countries, ketamine is sometimes used as a sole anesthesia agent during surgeries.

Ketamine is general very safe, but some considerations must be taken for patient safety.

Emergence reactions are not uncommon and may include hallucinations, disorientation,

nausea, and anxiety. Keeping the patient in a quiet room with low lighting can help avoid

emergence reactions. Use with caution in combination with other drugs, including sedative

agents, or in patients who have taken street drugs. Ketamine may worsen schizophrenia

symptoms, and may cause hypotension in severely catecholamine-depleted patients.

Although a major benefit of ketamine is its tendency to leave patient respiratory and airway

protective drives intact, patient level of consciousness and breathing should be

carefully monitored, especially with higher doses. This has recently been demonstrated in

the news stories about the death of actor Matthew Perry, and the manslaughter trial of two Aurora, CO paramedics, whose patient died after being given ketamine.

2018 JEMS: Should Ketamine Be Contraindicated for Patients with Traumatic Brain Injury?

"The_Drug_of_War"--a_historical_review_of_the_use_of_Ketamine_in_military_conflicts 

"The potential of ketamine for posttraumatic stress disorder: a review of clinical evidence"

2008 US Military Study: "The correlation between ketamine and posttraumatic stress disorder in burned service members". Found a lower incidence of PTSD amongst burned soldiers who were given ketamine, in a 147-patient sample.

2014 US military Study: "The intraoperative administration of ketamine to burned U.S. service members does not increase the incidence of post-traumatic stress disorder"  larger retrospective data analysis of ketamine use and PTSD development in 298 burn patients serving in the US military. This study did not find that ketamine offered PTSD-protective effects seen in previous smaller studies, but ketamine also did not worsen likelihood of PTSD development. 

2021 US military study: Ketamine Use in Operation Enduring Freedom - shows increasing usage of ketamine within the US military during the Afghanistan/Iraq campaigns.

2015 Emergency Physicians Monthly article: Battle Tested: Ketamine Proves its Worth on the Front Line

2014 study: The effect of ketamine on intracranial and cerebral perfusion pressure and health outcomes: a systematic review
A review of available literature found that ketamine did not produce significant changes in
cerebral perfusion pressures, neurologic outcomes, length of ICU stay, or mortality.

Two Aurora paramedics charged in Elijah McClain’s death defend actions, say police officers hurt their efforts to treat him