POW Patients: Geneva Convention, Part 1

 

Key Points:

Prisoners of War (POWs) are combatants (regular military, organized, uniformed militia, and local residents who spontaneously resist invasion) and noncombatants (journalists, civilians, supply contractors, etc) who have fallen into the power of the enemy.

POWs must at all times be humanely treated, and protected from: 

acts or omissions that could cause death or seriously endanger health or cause mutilation

medical or scientific experiments

acts of violence or intimidation 

insults and public curiosity

Prisoners of war may not be prevented from presenting themselves to the medical authorities for examination. Medical inspections of prisoners of war shall be held at least once a month.

Prisoners of war suffering from serious disease, or whose condition necessitates special treatment, a surgical operation or hospital care, must be admitted to any military or civilian medical unit where such treatment can be given

POWs must be adequately fed and watered, and clothed and quartered appropriately for the weather conditions

POWs should be allowed to send and receive mail

Unless he be a volunteer, no prisoner of war may be employed on labour which is of an unhealthy, dangerous, or humiliating nature.

POWs should not be intentionally exposed to fire, or used as “shields”

The use of weapons against prisoners of war, especially against those who are escaping or attempting to escape, shall constitute an extreme measure, which shall always be preceded by warnings appropriate to the circumstances.

FULL TEXT, RELEVANT EXCERPTS FROM THE 1949 GENEVA CONVENTION RELATIVE TO THE TREATMENT OF POWs:

*** All text below is taken directly from the original 1949 Geneva Convention Relative to the Treatment of Prisoners of War 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***

Prisoner of War Definition: 

A. Prisoners of war, in the sense of the present Convention, are persons belonging to one of the following categories, who have fallen into the power of the enemy:

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.

…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, who shall provide them for that purpose with an identity card similar to the annexed model.

…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, Part 1, Article 4)

General Treatment of Prisoners of War

Prisoners of war must at all times be humanely treated. Any unlawful act or omission by the Detaining Power causing death or seriously endangering the health of a prisoner of war in its custody is prohibited, and will be regarded as a serious breach of the present Convention. In particular, no prisoner of war may be subjected to physical mutilation or to medical or scientific experiments of any kind which are not justified by the medical, dental or hospital treatment of the prisoner concerned and carried out in his interest.

Likewise, prisoners of war must at all times be protected, particularly against acts of violence or intimidation and against insults and public curiosity.

Measures of reprisal against prisoners of war are prohibited.

 (1949 Geneva Convention, Article 13)

…All effects and articles of personal use, except arms, horses, military equipment and military documents shall remain in the possession of prisoners of war, likewise their metal helmets and gas masks and like articles issued for personal protection. Effects and articles used for their clothing or feeding shall likewise remain in their possession, even if such effects and articles belong to their regulation military equipment.

…Badges of rank and nationality, decorations and articles having above all a personal or sentimental value may not be taken from prisoners of war.

Sums of money carried by prisoners of war may not be taken away from them except by order of an officer…The Detaining Power may withdraw articles of value from prisoners of war only for reasons of security 

(1949 Geneva Convention, Article 18)

The evacuation of prisoners of war shall always be effected humanely and in conditions similar to those for the forces of the Detaining Power in their changes of station.

The Detaining Power shall supply prisoners of war who are being evacuated with sufficient food and potable water, and with the necessary clothing and medical attention. The Detaining Power shall take all suitable precautions to ensure their safety during evacuation, and shall establish as soon as possible a list of the prisoners of war who are evacuated.

 (1949 Geneva Convention, Article 20)

No prisoner of war may at any time be sent to or detained in areas where he may be exposed to the fire of the combat zone, nor may his presence be used to render certain points or areas immune from military operations…

 (1949 Geneva Convention, Article 23)

Prisoners of war shall be quartered under conditions as favourable as those for the forces of the Detaining Power who are billeted in the same area… 

 (1949 Geneva Convention, Article 25)

The basic daily food rations shall be sufficient in quantity, quality and variety to keep prisoners of war in good health and to prevent loss of weight or the development of nutritional deficiencies. Account shall also be taken of the habitual diet of the prisoners…Sufficient drinking water shall be supplied to prisoners of war. The use of tobacco shall be permitted…Collective disciplinary measures affecting food are prohibited…

 (1949 Geneva Convention, Article 26)

Clothing, underwear and footwear shall be supplied to prisoners of war in sufficient quantities by the Detaining Power, which shall make allowance for the climate of the region where the prisoners are detained… 

 (1949 Geneva Convention, Article 27)

Prisoners of war shall enjoy complete latitude in the exercise of their religious duties, including attendance at the service of their faith, on condition that they comply with the disciplinary routine prescribed by the military authorities.

 (1949 Geneva Convention, Article 34)

The use of weapons against prisoners of war, especially against those who are escaping or attempting to escape, shall constitute an extreme measure, which shall always be preceded by warnings appropriate to the circumstances.

 (1949 Geneva Convention, Article 42)

…The transfer of prisoners of war shall always be effected humanely and in conditions not less favourable than those under which the forces of the Detaining Power are transferred. Account shall always be taken of the climatic conditions to which the prisoners of war are accustomed and the conditions of transfer shall in no case be prejudicial to their health.

The Detaining Power shall supply prisoners of war during transfer with sufficient food and drinking water to keep them in good health, likewise with the necessary clothing, shelter and medical attention…

 (1949 Geneva Convention, Article 46)

Immediately upon capture, or not more than one week after arrival at a camp, even if it is a transit camp, likewise in case of sickness or transfer to hospital or another camp, every prisoner of war shall be enabled to write direct to his family, on the one hand, and to the Central Prisoners of War Agency…

 (1949 Geneva Convention, Article 70)

Prisoners of war shall be allowed to receive by post or by any other means individual parcels or collective shipments containing, in particular, foodstuffs, clothing, medical supplies and articles of a religious, educational or recreational character…

 (1949 Geneva Convention, Article 72)

Prisoners of war may not be sentenced by the military authorities and courts of the Detaining Power to any penalties except those provided for in respect of members of the armed forces of the said Power who have committed the same acts… Collective punishment for individual acts, corporal punishment, imprisonment in premises without daylight and, in general, any form of torture or cruelty, are forbidden.

 (1949 Geneva Convention, Article 87)

Escape or attempt to escape, even if it is a repeated offence, shall not be deemed an aggravating circumstance if the prisoner of war is subjected to trial by judicial proceedings in respect of an offence committed during his escape or attempt to escape.

In conformity with the principle stated in Article 83, offences committed by prisoners of war with the sole intention of facilitating their escape and which do not entail any violence against life or limb, such as offences against public property, theft without intention of self-enrichment, the drawing up or use of false papers, or the wearing of civilian clothing, shall occasion disciplinary punishment only.

 (1949 Geneva Convention, Article 93)

Medical Treatment of Prisoners of War

The Power detaining prisoners of war shall be bound to provide free of charge for their maintenance and for the medical attention required by their state of health.

 (1949 Geneva Convention, Article 15)

Prisoners of war who, owing to their physical or mental condition, are unable to state their identity, shall be handed over to the medical service.

 (1949 Geneva Convention, Article 17)

Prisoners of war shall be evacuated, as soon as possible after their capture, to camps situated in an area far enough from the combat zone for them to be out of danger.

Only those prisoners of war who, owing to wounds or sickness, would run greater risks by being evacuated than by remaining where they are, may be temporarily kept back in a danger zone.

 (1949 Geneva Convention, Article 19)

Every camp shall have an adequate infirmary where prisoners of war may have the attention they require, as well as appropriate diet. Isolation wards shall, if necessary, be set aside for cases of contagious or mental disease.

Prisoners of war suffering from serious disease, or whose condition necessitates special treatment, a surgical operation or hospital care, must be admitted to any military or civilian medical unit where such treatment can be given, even if their repatriation is contemplated in the near future. Special facilities shall be afforded for the care to be given to the disabled, in particular to the blind, and for their rehabilitation, pending repatriation…

…Prisoners of war may not be prevented from presenting themselves to the medical authorities for examination.

 (1949 Geneva Convention, Article 30)

Medical inspections of prisoners of war shall be held at least once a month. They shall include the checking and the recording of the weight of each prisoner of war. Their purpose shall be, in particular, to supervise the general state of health, nutrition and cleanliness of prisoners and to detect contagious diseases, especially tuberculosis, malaria and venereal disease…

 (1949 Geneva Convention, Article 31)

Sick or wounded prisoners of war shall not be transferred as long as their recovery may be endangered by the journey, unless their safety imperatively demands it…

 (1949 Geneva Convention, Article 47)

 

Duties of the Prisoner

Every prisoner of war, when questioned on the subject, is bound to give only his surname, first names and rank, date of birth, and army, regimental, personal or serial number, or failing this, equivalent information.

…No physical or mental torture, nor any other form of coercion, may be inflicted on prisoners of war to secure from them information of any kind whatever. Prisoners of war who refuse to answer may not be threatened, insulted, or exposed to any unpleasant or disadvantageous treatment of any kind.

 (1949 Geneva Convention, Article 17)

Prisoners of war who, though not attached to the medical service of their armed forces, are physicians, surgeons, dentists, nurses or medical orderlies, may be required by the Detaining Power to exercise their medical functions in the interests of prisoners of war dependent on the same Power. In that case they shall continue to be prisoners of war, but shall receive the same treatment as corresponding medical personnel retained by the Detaining Power. They shall be exempted from any other work under Article 49.

 (1949 Geneva Convention, Article 32)

Members of the medical personnel and chaplains while retained by the Detaining Power with a view to assisting prisoners of war, shall not be considered as prisoners of war. They shall, however, receive as a minimum the benefits and protection of the present Convention, and shall also be granted all facilities necessary to provide for the medical care of, and religious ministration to, prisoners of war.

 (1949 Geneva Convention, Article 33)

The Detaining Power may utilize the labour of prisoners of war who are physically fit, taking into account their age, sex, rank and physical aptitude, and with a view particularly to maintaining them in a good state of physical and mental health.

 (1949 Geneva Convention, Article 49)

Unless he be a volunteer, no prisoner of war may be employed on labour which is of an unhealthy or dangerous nature.

No prisoner of war shall be assigned to labour which would be looked upon as humiliating for a member of the Detaining Power's own forces.

The removal of mines or similar devices shall be considered as dangerous labour.

(1949 Geneva Convention, Article 52)

Links

Geneva Convention, full text relating to treatment of Prisoners of War

International Committee of the Red Cross POW Website

Doctors Without Borders’ Practical Guide to Humanitarian Law

Video by Third Brigade of Capture and Interview of Russian POWs

5,389 documented cases of Russian use of chemical weapons in Ukraine

The Ukrainian General Staff reported on January 18 that Russian forces used ammunition equipped with chemical agents banned by the Chemical Weapons Convention (CWC) 434 times in Ukraine in December 2024, contributing to a total of 5,389 documented cases since February 2023.[1] Ukraine's radiation, chemical, and biological intelligence units are monitoring Russia's use of banned chemical agents, which include using regulated K-51 and RG-VO grenade launchers to launch munitions containing chemical agents and ammunition containing unspecified hazardous chemicals that are banned in warfare under the 1925 Geneva Protocol and CWC. Ukrainian officials have previously reported on increasingly common instances of Russian forces using chemical substances in combat that are banned by the CWC, to which Russia is a signatory, and the Ukrainian General Staff noted that such violations have been systematic in the Russian military since February 2023.

Soldier in Traumatic Cardiac Arrest Saved by Ukrainian Medics

 

Ukrainian Army Recruiting Ad

 

Anti-Drone Cage on Russian Oil Tanks

 

Russian soldiers downs drone by throwing his rifle at it

 Very pro-Russian propaganda video here, but there's an interesting moment at minute 4:20

Chinese Army Drone Training

 

"2000 Meters to Andriyivka": a film with the Third Assault Brigade at the American Sundance film festival!

This is a film from Oscar-winning Ukrainian film director Mstislav Chernov. With footage of real battles, losses, and victories of fighters of the 2nd mechanized and 2nd assault battalions of the 3rd assault brigade during a counteroffensive in the summer of 2023.

The world premiere of the film about the operation to liberate Andriyivka near Bakhmut will take place on January 23 at the SUNDANCE festival in the USA.

About the fight for every centimeter of our land, the happiness and horror of war, the fighters who take it out, and pre-premiere footage — in the video commentary!

Ukraine: Mines and Mine Injury Patterns

 MINES AND MINE INJURY PATTERNS

Modern mines have been in use since WWII, and mine-like devices have been used for centuries. In 1997, 164 nations (including Ukraine) signed the Anti-Landmine “Ottawa Treaty”. This treaty prohibits the production, stockpiling, transfer, and use of anti-personnnel mines. The US, Russia, and China have not signed the Ottawa Treaty, nor have they joined the other 124 signatories to the 2008 CCM Treaty, which prohibits cluster munitions. Under the Geneva Conventions (signed by China, the US, Russia, and Ukraine), it is considered a war crime to place minefields without marking and recording them for later removal

A major driver of these treaties was the fact that mines pose an enduring risk post-conflict. Most landmine victims are civilians. Mines cost as little as $3 each to produce, but may cost $1,000 apiece to remove. New “smart mines” are designed to self-destruct after a certain amount of time; however, they do not do so reliably.  It is estimated that over 110 million active landmines are still buried in over 60 countries around the world. 

Both Ukraine and Russia have placed mines in the Ukraine War. Ukraine is currently the most heavily mined country in the world. It is considered “massively contaminated”, with more than 2 million mines affecting 40% of Ukrainian territory. IN EAST UKRAINE, ALWAYS ASSUME ANY GROUND OR STRUCTURES THAT DO NOT RECEIVE REGULAR FOOT OR VEHICLE TRAFFIC ARE CONTAMINATED WITH MINES OR OTHER UXO.  Over 70% of minefields and battle areas assessed by HALO Trust in Kharkiv and Mykolaiv Oblasts contain complex clearing challenges such as tripwires, magnetic influence mines, stacked mines, and seismic mines. HALO is pioneering new clearing technologies, such as survey drones and AI satellite imagery analysis. 

Mines are broadly categorized as either  anti-personnel (triggered by as little as 5-15kg) or anti-vehicle (triggered by ~100+ kg). Uses include defensive barriers, disrupting or channeling enemy movements, and protection of strategic areas. Mines may be buried, emplaced above ground by hand, or delivered by aircraft or rockets.They may be triggered by pressure, tripwire, magnets, time mechanism, or the command of an observer. In most models, activation drives a firing pin into a detonator cap, which ignites the main charge.   

In Ukraine, mines are not the only UXO threat in former conflict areas. Empty structures and fortifications may be booby-trapped by retreating forces with tripwire mines and other explosive hazards.

Many antipersonnel mines are designed to injure rather than kill, in order to increase logistical burden on the enemy. ICRC has identified three main landmine injury patterns:

Pattern 1: Blast Mines

A victim stands in a buried landmine, causing a traumatic amputation of a lower limb. The blast wave travels up the leg, fracturing bone. Blast gases strip flesh from bone, disrupt vascular and nerve attachments, and drive fragments from the soil and mine casing deep into the flesh. The blast may separate skin from underlying tissue and muscle, and it may burst tissues where fluid and air are next to each other (eardrums, bowel, lungs). 

Pattern 2: Fragmentation Mines

A victim is injured by multiple fragments from an exploding landmine, causing penetrating injuries to the head, neck, and abdomen. Bounding mines spring up to a height of about 1 meter before releasing fragments. Fragments consist of many small metal balls or other materials. There may be little obvious injury other than many small puncture wounds, however the potential for internal bleeding and infection is extremely high.

Pattern 3: Blast or Fragmentation Mines

A victim handles a landmine, causing severe injuries to the upper limbs and face, including eyes. 

Buried blast mines pose the greatest lingering clearance challenges worldwide. The ground in which a mine is buried has a huge affect on the amount of blast energy is delivered to the victim. When the mine detonates, 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. 

Recovery is generally prolonged, and may be complicated by infection, phantom pain, and the need for multiple surgeries. With a prosthesis, an above-knee amputation requires about 100% more energy to walk, while a below-the-knee amputation only requires 15% more energy. REPOSITIONING A TOURNIQUET AS LOW AS POSSIBLE ON THE AMPUTATED LIMB CAN HAVE A MAJOR EFFECT ON FUTURE QUALITY OF LIFE.

Anti-Vehicle Mine injury patterns:

First, If the blast penetrates the floor or sides of the vehicle, occupants are exposed to blast pressure, heat, and fragments from the mine, earth, and floor of the vehicle. The floor of the vehicle adjacent to the breach may deform and produce additional blunt and penetrating injuries.

Second, the floor may remain intact, but act as a “drum”, turning loose objects in the vehicle into projectiles. Floor deformation and sudden loading forces may cause fractures to long bones and the spinal column.

Third, the force of the blast may throw or overturn the vehicle without penetrating the floor or sides. 

ICRC Anti-personnel landmines page

APOPO- Anti-Personnel Landmines Detection Product Development

CEPA: An Explosive Choice: Landmines and Ukraine

Landmines- all you Never Wanted to Know, by the SJH Project

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CAN YOU FIND THE TWO PETAL MINES IN THE PICTURE?

ISW Ukraine Conflict Update Excerpt on Tanks and Tactics, January 2025

 "Russia's current armored vehicle and tank production rates indicate that such losses will likely be prohibitive over the longer term, particularly as Russia continues to dip into its Soviet-era stocks.[3] Ukrainian military observer Kostyantyn Mashovets stated in February 2024 that the Russian defense industrial base (DIB) can produce 250-300 "new and thoroughly modernized" tanks per year and can repair roughly 250-300 additional damaged tanks per year, far below Ukraine's estimate of 3,600 Russian tanks lost in 2024.[4] The British International Institute for Strategic Studies (IISS) think tank also reported in February 2024 that Russia is likely able to sustain its rate of vehicle losses at that time (over 3,000 armored fighting vehicles including tanks, armored personnel carriers, and infantry fighting vehicles annually as of 2023 and nearly 8,800 between February 2022 and February 2024) for at least two to three years (until about February 2026 or 2027) by mainly refurbishing vehicles from Soviet-era storage facilities.[5] A social media source tracking Russian military depots via satellite imagery shared an updated assessment of Russian tank and armored vehicle storage facilities on December 22 and assessed that Russian forces have 47 percent of their pre-war tank reserves, 52 percent of pre-war infantry fighting vehicle reserves, and 45 percent of pre-war armored personnel carrier reserves remaining in storage as of a recent unspecified date.[6] The social media source noted that Russian forces have used most of their newer T-90 and T-80 tanks but still have a majority of their older tanks in storage, although some of these tanks have likely been heavily degraded by weather and time. It appears increasingly unlikely that the Russian military can sustain its current annual rate of almost 9,000 armored vehicle losses through 2025. This loss rate is nearly three times the annual loss rate of the first two years of the war according to IISS, suggesting that the February 2024 IISS estimate that Russia can sustain its vehicle losses through 2025 and possibly 2026 is no longer valid.

Russian forces have reportedly been using fewer armored vehicles in assaults in the most active areas of the frontline in recent weeks, possibly in order to conserve these vehicles as Soviet stocks dwindle. Ukrainian military sources have recently noted that Russian forces have been using fewer armored vehicles and conducting fewer mechanized assaults in the Kurakhove direction after suffering significant vehicle losses in October and November 2024.[7] The spokesperson of a Ukrainian brigade operating in the Kurakhove direction stated on January 3 that Russian forces have switched to mainly using infantry to conduct assaults in the area over the past few weeks and are only using armored vehicles as fire support for infantry assaults.[8] The New York Times reported on December 31 that a Ukrainian lieutenant colonel stated that Russian forces are increasingly using electric scooters, motorcycles, and all-terrain vehicles (ATVs) during assaults in eastern Ukraine, possibly as part of ongoing Russian efforts to offset armored vehicle losses.[9] Russian attacks near more mid-sized, urban settlements such as Kurakhove and Pokrovsk may also be less conducive to mechanized assaults than the small settlements and open fields where Russian forces advanced in most of 2024. Russian forces may be using fewer armored vehicles in the Kurakhove and Pokrovsk directions if the Russian military is struggling to reequip frontline Russian units and formations and if Russian military command does not want to withdraw Russian units for rest and reconstitution and risk further slowing Russian advances in high-priority frontline sectors."

"...A spokesperson of a Ukrainian brigade operating in the Lyman direction reported on January 17 that Russian forces typically attack in groups of two where one unarmed soldier advances to expose Ukrainian firing positions, and then the second well-armed soldier approaches and begins firing on Ukrainian positions.[43] The spokesperson noted that Russian forces prefer to relegate convict recruits to the role of the unarmed soldier and noted that the Russian units in the area still possess a significant number of convict recruits for such attacks..."

- From Institute for the Study of War Ukraine Conflict Update database

Ukraine: Vehicle is Hunted by a Drone

 

Viktor and Olena Pinchuk create all-Ukrainian network of mental health centers for military personnel: "RETURN"

The nationwide RETURN project aims to support the mental health of military personnel, veterans, and their families who have suffered psychological trauma as a result of Russian aggression in Ukraine. It aims to provide not only access to professional mental health care, but also systemic support for those who have survived the most difficult moments of the war.

▪️ System assistance throughout the country

 The first stage of the RETURN project involves the opening of 25 mental health centers in all regions of Ukraine. The centers will operate on the basis of state medical institutions and will provide free outpatient services. The first center is planned to open in Dnipro in early 2025.

▪️ Training for professionals

 A key component of the RETURN project will be the training of medical professionals to world standards, ensuring quality support and recovery for those who have survived the horrors of war. This is another important step towards the mental recovery of our nation.

 The RETURN mental health project will become another key area of ​​support for military personnel, veterans, and their families. In early 2023, Victor and Olena Pinchuk launched a national network of rehabilitation centers for wounded military personnel, RECOVERY. During this time, 15 innovative and barrier-free centers have been opened, providing high-quality and free services to over 20,000 wounded military personnel. Within the framework of the RECOVERY educational program, over 3,000 medical professionals have undergone training and experience exchange programs, including in the USA, Austria, Latvia, Estonia, Lithuania, Switzerland, and Norway.

Video: Low-Flying Shahed Drone

 

 

Video: Impact of a FAB-500 Glide Bomb, Ukraine

 

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: 2024 Russian Casualty Stats

 The Ukrainian Ministry of Defense has reported that Russia seized 4,168 square kilometers in Ukraine and Kursk Oblast in 2024. This came at the cost of 427,000 casualties. 

This equates to 102 Russian casualties per square kilometer of ground taken.

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: First Shoot Down of an Enemy Helicopter by a Maritime Drone

 Ukrainian Defense Intelligence (HUR) announced today the first successful destruction of an aerial target using a marine drone. The drone, a Magura V5, is reported to have shot done one Russian Mi-8 helicopter with a SeaDragon missile, and damaged a second helicopter.

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