By Matthew Parish
Rather enthusiastically and on invitation, I signed up to a joint civilian-military nine-day course of medical training for combat scenarios in a military training centre outside Kyiv, in the month of September, although the precise details will obviously not be revealed. The course started buoyantly enough. It was run by a team of Americans, and they were all working on the course as volunteers; but so was I: I had to pay for my travel to and residence at Kyiv in a truly gruelling bedbug hotel near the military facility, in the middle of nowhere, and I had to pay for my food and drink. My time was not compensated. I imagined I would then be deployed to a place where, as a volunteer or otherwise, I could use my newly trained medical skills to assist wounded soldiers. However it was not to be. I learned a huge amount; but I did not learn quite what I had expected.
Tactical Combat Casualty Care is a series of US Government Department of Defense Health guidance on how to treat combat casualties at so-called “stabilisation points” pending their evacuation to hospitals for treatment by qualified doctors. I had been trained in this skill some ten years ago in a joint civilian-military course with 22 / 23 Regiment Special Air Service, and I had received a paramedic qualification as a result. I was taught that 95% of people who reach a field hospital from the stabilisation point live, and therefore the works of the carers undertaken at the stabilisation point is very important indeed. Essential skills are to keep the heart beating (including CPR if necessary), the patient breathing (airway restrictions must be unblocked) and massive haemorrhaging of blood must be addressed. So this work is very important. However these skills cannot be taught in a nine-day course and indeed they were not. A minimum of 16 weeks is typical to learn the skills for work at a stabilisation point, and most of the time necessary to learn these skills is learned on the job.
Instead what we had on this course was a bizarre mixture of two things. One was a rapid-rattle reading-out of the TCCC guidelines by an instructor who had no obvious qualifications at all apart from the capacity to read extremely quickly: so quickly that it was impossible to take notes and the information imparted just went in one ear and out of the other. Then, every couple of hours, we would be taken outside for so-called “simulations”. What this meant was that, without virtually any medical equipment at all to practise on (even the tourniquets intended to stem limb blood flow were of the flimsy Chinese variety), we would be divided into teams and then one person would be told to fall over and start screaming. The others, then anticipating that they might be under fire (a wooden children’s toy gun was even deployed for this purpose; only one person turned up to the course with an actual gun, a Spanish speaking member of the International Legion), would run towards the “casualty” and haul him over rough ground using rope to an imaginary “stabilisation point” at the other end of the piece of grass outside the military facility. This was all rather silly although I did learn how to pull a person with a piece of rope. (You guide it under their back, then up through their arms, crossing it without endangering their airway and then one or two of you can pull the heaviest character a long distance.)
I was told that day #1 was civilian clothes only so I didn’t bring my military fatigues. Nevertheless we were doing this silliness by 11am on the first day so that was one decent pair of jeans lost as I was repeatedly pulled over the rubble. Then we were supposed to apply tourniquets to limbs; this is a simple exercise, and I can teach anyone how to apply or remove a tourniquet in about five minutes. However the key with tourniquets is not to leave them on too long; the fact that they are left on too long may be one explanation for all the amputations we sadly see around Ukraine. The taught was course strictly as a lecture that the TCCC guidelines represent exactly what to do but of course medicine is not like this. Military people are used to following orders unquestioningly but civilian people are not and I asked questions about mortality rates, amputation rates and the like all of which were distinctly unwelcome because I sensed that the trainers did not know the answers. With the exception of one Ukrainian teacher, whose role in the course was far too limited, none of the trainers were practising or had practised at the front line. So we were just having guidelines dictated to us that we could more easily have read on pieces of paper.
The practical exercises acquired an increasing sense of the ludicrous as we were meted out with punishments every time we got it “wrong” (e.g. we didn’t pull the person quickly enough or didn’t apply a tourniquet - itself a dangerous piece of medical equipment to be used cautiously) - tightly enough. I felt like I was in a scene from the Stanley Kubrick dystopian war movie Full Metal Jacket as the entire class was engaged in collective punishment of doing 10 squat thrusts or push ups for the mildest misdemeanour. At one point the instructor threatened us all with 45 push-ups per morning if we didn’t put our plastic bottles in the waste bin. A polite “would you mind cleaning up after you?” might have been a more effective means of persuasion, in particular for the civilian members of the team. We were taught other life saving procedures, but all in theory and with a total absence of equipment that made the procedures being taught farcical. I could give many examples, but one will suffice.
There is a technique in airway management called a crycrothyrotamy that involves slicing open the skin on the throat with a scalpel vertically, then pushing the scalpel through horizontally through the crychothyroid membrane in order to establish an airway for ventilation in the event that the throat or mouth are blocked and you cannot safely remove the blockage. It is rare and frankly an extremely dangerous intervention that should only be performed by surgeons; but we were taught how to do it with dummies. (In practice no combat paramedic would ever do this; everyone in the room who had tried it admitted that their patient had died.) Then we were going to try it ourselves on pigs’ heads. This seemed fair enough; only someone had bought pigs’ thighs from the butchers by mistake, presumably wanting to make a tasty barbecue from them. So there was a delay while the right person went back to the butcher’s. Then it turned out they had bought frozen pigs’ heads, and only two of them; so we had to wait for them to thaw out, while being given obvious lectures about the importance of wearing surgical gloves while undertaking this procedure. By the time it came my turn to practice on a thawed pigs’ head, it had so many scalpels and pipes stuck through its neck that it had turned to a lump of jelly and there was nothing left to practice on. This sort of operation should be practiced first in a clean hospital environment, with proper animal parts that have not been desecrated by dozens of others, before moving to a field environment where you are almost invariably practising on your knees. The whole thing was silly and I am the first to admit that I would be totally unsafe performing this procedure. It should never have been taught to me or anyone else in such a way.
Then I learned how to fold and unfold Soviet-era stretchers. They are unusable, by the way, because they are so thick and heavy that you cannot carry them around the corners in trenches. A standard American folding stretcher is very difficult to carry people in. There are however some excellent modern stretchers that let you pull people along the ground, zipped up in what look like rugged if extremely thin sleeping bags with ropes to pull them.
The average price for good equipment for a stabilisation point field medic is easily in excess of US$2,000, not including the bags themselves or the body armour necessary for field operations. The soldiers and civilians being assigned to stabilisation points are being told to buy their own equipment.
By day two of this course, my questioning of the practices and ways of learning involved in this course was increasingly of open irritation to the instructors, who despite did not themselves (with one notable Ukrainian exception) have substantial field experience. I wondered whether they had less training than me in how to act under fire - I have been a UN peacekeeper and I have operated alongside the military of various countries in a number of wartime or postwar situations. So after classes on day # 2, the instructors took me aside and told me that they had already decided not to grant me the certificate that is awarded to participants who complete the course, and I asked why not. They told me that I am a civilian and this is a course for military people. I asked why therefore they had admitted me to this course, if I was ipso facto excluded because I am not a member of any military unit. Their reply to this was that I am fat. This was not only offensive; it was also absurd because I was perhaps the fifth or sixth fattest person in the class and the fattest person of all in the room was one of the trainers who, with the greatest of respect to him, looked like he had enjoyed a meal of junk food three times a day for the last twenty years. I said that I insisted that they maintain me on the course and assess me just as they would with any other member of the course (I was not the only civilian). But these people clearly had no experience in civilian-military interactions whereas I have plenty.
On day # 3 an extremely aggressive American paramedic entered the classroom and gave us a nonstop Powerpoint-based lecture on drug administrations for some of the world’s most lethal and dangerous painkillers, including fentanyl and ketamine. He also gave us the dosages for medications in case you overdose your patient and you are about to kill them. He rattled off a series of American antibiotics without mentioning the many other painkillers, antibiotics and other medications that you can administer on the battlefield that involve much less risk and are oftentimes easier to obtain. Nobody in that room had a licence to administer fentanyl or ketamine whether on the battlefield or otherwise and they shouldn’t have been teaching us how to do these things. Then we were dragged over some rocks again using ropes in simulated “extraction” sessions in the yard, ripping my second pair of trousers, by this time my military fatigues.
The same American paramedic, who is not actually working as a paramedic in Ukraine (he has an online job and just teaches this course on illicit days off, having thereby having lost all his paramedic experience), would occasionally single me out for interrogation about my paramedic experience with what is known colloquially in Britain as “the Regiment”, jealously eyeing my Special Air Service patch. I played dumb in response to these mock interrogations, knowing they were driven solely by envy.
Days four and five were just rapid-fire readings of Powerpoint slides that are much easier to read in a book. But we were given none of the standard textbooks, comprehensive familiarity with which is obviously essential to serve as a combat medic without causing damage.
I would go home to my bedbug palace with my new friends and colleagues, civilian and military, each evening and discuss how irritated we were with the amateurish nature of this course. We had to pretend to apply chest seals: they didn’t let us open one because they didn’t have enough of them. We learned how to apply IV drips on dummies but not on dead bodies because they didn’t have any of them. It is not hugely difficult to insert an IV drip as long as you have plenty of experience on real tissue. This was demonstrated when the jealous paramedic tried to insert an IV drip on one patient who volunteered. The paramedic attempted to do this repeatedly, only to make a blood-splattering mess of it all that was then circulated on the group chat for the class.
I was ridiculed in class for the quality of my body armour, even though it was of a higher class (Class IV lead-steel body armour) than many of the other members of the class, some of whom even came with no helmets. Apparently this made me an unsuitable member of the class, in particular because my plate carrier is blue (indicating a civilian) rather than green (indicating a member of the military). Notwithstanding, at least I had brought a plate carrier and I felt that I shouldn’t have been discriminated against for wearing civilian colours because I am, in fact, a civilian. Another civilian member of the class appeared pressurised into buying an expensive set of body armour on the spot in the middle of the day, even though no list of necessary equipment had been supplied in advance of the course telling us what we had to bring.
Much medical care in the battlefield has to be undertaken in the dark, and this entails the use of night vision goggles. The class teachers didn’t have any of these and anyway their teaching dummies were all carved up so it was impossible to practise medical interventions using the equipment the tutors were providing. Thankfully one of the other students had some and those were used in a brief attempt to make the practical medical scenarios more realistic. However this was far from satisfactory.
However by this time I had lost patience with tutors who did not apparently have the necessary qualifications, equipment or skills for what they were teaching (we were given only one needle each) and who had distributed mobile ‘phone Apps containing course materials one of which I couldn’t download at all and the other of which had manifest bugs and problems in its operation. By Friday evening I came to the definitive realisation that this was not a serious course at all and I woke up bright and breezy on Saturday morning, put on my best military fatigues (or what was left of them), and strolled into the base where we were being taught and politely resigned on the spot. The course was intended to be full-time over the weekend and nobody can sensibly take in all this material without even having a weekend break: massive quantities of data about medicine types and dosages, and information about surgical procedures the students were obviously not skilled or licensed to undertake. The principal instructor even admitted that there were parts of the course that she could not teach, because she was still learning them on the internet.
I spent my weekend doing more useful things to help Ukraine, and I came back to the bedbug palace each evening only to hear my fellow students recount tales of how the course had become even more incompetent and disorganised after I had left it. Their faces said it all: they were tired of this, and sick of the lack of organisation in the course. I had brought with me US$1,000 or so of medical equipment to donate to the course providers, but in the end I decided to donate it to an NGO who seem much more committed to providing medical supplies directly to front line and have the eminent expertise to do so with far greater skill.
I had also in the interim contacted the International Legion of the Armed Forces of Ukraine and they had explained to me that the certificate the course providers issue at the end of the course is not recognised by them so the certificate I would have obtained had I lasted the course out would be of no use to me in my support for the Ukrainian Armed Forces.
Moreover the course was in English, so only very few Ukrainian soldiers could participate in it (a handful who spoke English). The Spanish-speaking members of the Ukrainian Armed Forces who were present would presumably have very limited capacity to learn anything from the course, because at least two out of three of them don’t speak English and therefore I don’t see how they were to pass the practical part of the examination that includes a multiple choice examination in English (at least according to the notes accompanying the pre-course materials).
What lessons are we to draw from this chaotic affair? There are number of them, and the lessons I learned I try to encapsulate below.
Firstly, the provision of medical support services to the Armed Forces of Ukraine, in circumstances in which detailed medical training is not available to the Ukrainian Armed Forces, is inevitably going to be a combination of civilian and military personnel doing their best in limited circumstances. This was supposed to be a combined civilian-military course and it failed in that objective. I was not the only civilian member of the course discriminated against. The course should have been adapted to combined civilian-military personnel, as have been other courses I have attended in other jurisdictions. Combat medicine works best when civilians and military personnel cooperate together, and that requires teachers who understand the differences between civilian and military modes of operation and can bring them together.
Secondly, the course was underfunded and therefore disorganised and bereft of supplies. The instructors should have been paid, should have been trained in working with both civilians and the military, and they should have organised their training materials better. They should have had the appropriate qualifications and recent experience and, to repeat, with one exception, only one such trainer - who was excellent - had that combination of qualifications and experience.
Thirdly, there is a gross shortage of medical equipment on the front line infrastructure in Ukraine, including at stabilisation points and including ambulances to transport people from stabilisation points to hospitals. It seems that most of the equipment is donated. This will not do. If the mortality rates for wounded soldiers in the Ukrainian Armed Forces is to fall, and if we are to see less of the tragic loss of limbs that will scar Ukraine for a generation through mistakes made by under-trained and/or under-equipped military personnel at crisis points, then proper supplies of medical equipment and trained medical skill must be provided by the West because the moribund Ukrainian economy is unable to supply these things in the requisite quantities.
Fourthly, proper training ought to be provided in the nature of a medical training course of a minimum of 16 weeks so that the personnel undertaking medical relief at or close to the front line are not a liability (as I felt I would be had I deployed to the front line with this mere nine-day course under my belt) and instead can save troops’ lives. We need a massive injection of training, professional trainers and equipment and this needs to be provided in generous quantities by supporting western governments.
This is a war of attrition, and Ukraine needs its men back into civilian life, not with life-altering injuries, once this war comes to an end which I predict will be in 2025 when the US Government, one way or another after the US Presidential election this November, decides to step in and take definitive steps to end the war through proper military pressure on Russia. The need for adequate medical training for both civilians and the military, leading to qualifications that are actually recognised by the Ukrainian Armed Forces, is colossal. These are the messages I will be doing everything in my heart to press at the highest levels of government in the West and I very much hope they will take heed of this essential message to save Ukraine’s heroes when they are injured in the heat of battle. Slava Ukraini. Glory to the Heroes.
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Post scriptum 25 September 2024
Since originally writing this article it has come to light that there is a network of unlicensed, unregulated providers of so-called "TCCC" training across Ukraine, that the Ukrainian government does not recognise. We cannot comment on the quality of these various providers, but we note in passing that to the best of our understanding neither the US Government (that devised the TCCC guidelines) nor the Ukrainian government (whose soldiers and others deployed to the Ukrainian front line are being trained on these courses) either regulate or authorise these courses. For this reason, anyone within Ukraine offering "TCCC training" should be treated with caution.