There aren’t enough medical specialists on the front line in Ukraine. The net result is that more Ukrainian soldiers are dying when they are injured than ought to be; and that the long-term injuries those who survive suffer from are more serious, including more serious amputations than might be necessary were there more medically qualified personnel and better equipment and conditions.
For the most part medics with any qualifications are based in a series of so-called “stabilisation points”, basic field hospitals about 20 kilometres (sometimes more) from Zero Line positions. The medical staff at stabilisation points are often volunteers (Ukrainian and foreigners) and they live in varyingly poor conditions. Very few to no doctors will come to work at the stabilisation points; it is too dangerous. They will remain in hospitals to perform major trauma surgery in the cities behind the front line such as Dnipro, Mykolaiv and Kherson. The staff at the stabilisation points may or may not have serious qualifications and experience. Some of them may be qualified paramedics or nurses, or with paramedic certification. Others may have no formal qualifications and are just learning on the job. Facilities vary widely between stabilisation points. Some have basic equipment and medications; others do not. A lot of the equipment is donated; orders from the central government for supplies can take up to six months to reach a stabilisation point. (The same is true with orders for ammunition, incidentally.) The bureaucracy is horrendous and this is in part the consequence of corruption and in part Soviet-mentality inefficiency.
The job at stabilisation points is to treat minor injuries so that soldiers can, with a bit of rest, return to battle; or to stabilise more seriously injured patients in order that they be transported to regular hospitals where doctors and surgeons will treat them. However relatively few wounded soldiers make it to the stabilisation points. The Zero Line (where the greater majority of injuries and deaths are incurred) are generally not on roads (or not ones you can drive along). The front line, particularly in the Donbas, runs through a series of fields, flatlands, tree scapes and rolling rural land with the occasional small village. Villages sometimes become flashpoints in the front line conflict and often there is a report in the mainstream news that a village has been fiercely fought over. Most likely you have never heard of it; both sides fight to the death, street by street, building by building, but these are usually entirely insignificant settlements for strategic purposes but the Soviet style of fighting - just throwing limitless numbers of men at the battle - remains.
Other times the fighting is in the woods, amongst the trees, or involves attempts to storm trenches, in scenes reminiscent of World War I where Russian soldiers are instructed to go “over the top” and not to come back alive. In such circumstances the death rates for Russian soldiers are very high and their best hope is to be captured alive by Ukrainians and to become prisoners of war. These positions where soldiers are doing the fighting are typically 5 to 7 kilometres from the nearest road to which an ambulance can collect them. So if you are injured on the Zero Line, then you need to be treated by a combat medic and then carried, usually by stretcher, between 5 and 7 kilometres to the road where an ambulance or other civilian vehicle adapted to the task can drive you to the stabilisation point.
Rotations to the Zero Line and back are typically every 7 to 10 days and of course using reconnaissance drones, the Russians have worked out the rotation schedules. So it is a 5 to 7 kilometre run, with full pack, to get to and from the Zero Line positions in the Donbas, and you run along the tree line because that way it is more difficult for the FPV drones (small drones with grenades attached that act in a kamikaze fashion to strike individual soldiers) to hit the soldiers when they are moving to and from position. Drones cannot penetrate forests and their cameras are often not good enough to see into forests from the air. However where a period of open field has to be crossed, this is where the Russian drones are waiting and where they will strike. I have heard it said that the greater majority of casualties on the Ukrainian side are incurred when soldiers are engaged in this hike between Zero Line positions and the nearest (barely) usable road where they can be collected and returned to base or taken to a field hospital.
There are very few properly trained combat medics on the front line, the sorts of highly trained personnel whose actions on the front line can have life determining outcomes. In the United States combat medic training is typically a 16-week course and while the Ukrainian Armed Forces have formally adopted the so-called “TCCC” system of combat casualty care, in practice they are unable to implement it. This is because they do not have the training systems for 16 weeks; they do not have the medical supplies and equipment TCCC presumes; and TCCC was designed for situations of helivac (helicopter evacuations) where a helicopter could arrive within minutes and under cover of defensive fire. None of these things are possible on the front line in Ukraine. There are no helivacs because there are no helicopters and anyway modern drones would make landing a helicopter extremely dangerous. Therefore a handful of soldiers are given inadequate training of as little as a week and told to apply TCCC guidelines but of course they can’t do it. TCCC assumes the patient will be in a helicopter with adequate medical facilities on board within minutes and then in a decent hospital within an hour; it is a series of guidelines based upon asymmetric warfare but this is, in its own curious way, a symmetrical war in which each side is using the same basic, gruesome techniques.
Therefore if you are seriously injured on the front line, your evacuation time may be several days by which time you have already lost the limb that has had a tourniquet applied to it. Or you may simply have bled to death or become mentally unhinged. You need to find companions to carry you (or walk if you are the walking wounded) across the 5-7 kilometre gap to the road where hopefully an ambulance is waiting to meet you. Unfortunately there is a shortage of ambulances because all the ones donated by NGO’s seem to be sitting in large car parks or warehouses in Dnipro or Kyiv, not being distributed to stabilisation points or units that need them. The reason for this, as far as I can tell, is that the military is accepting these vehicles and then not distributing them to units without written request which no officer dare sign because he knows it may be construed as an admission that they have insufficient official equipment from the government. Ultimately these vehicles may be sold as part of the huge war profiteering effort that is underway in Ukraine.
If you are lucky enough to get an ambulance (and volunteers are now ever more reluctant to work at stabilisation points because there are no patients, and that is because there are no ambulances to bring them patients) then the drive to the stabilisation point may take a few hours along extremely bumpy, dangerous roads: dangerous because Russian drones know that ambulances use them and they will target the ambulances as well as personnel at the evacuation points: the Russians are not above targeting medical personnel, notwithstanding that it is a clear war crime. Once you are at the stabilisation point you will be patched up as best as possible depending on the facilities available, and then either returned to battle or transported onto a major hospital.
I have heard stories of stabilisation points without running water; with maggots in vacuum sealed bags of food, of people being unable to wash for a week or more; of unspeakable horrors in every respect. The stabilisation point I entered smelt and looked like a morgue but it was notable in the absence of patients; they weren’t there, because there weren’t ambulances to bring them there. There was inadequate electricity and not even adequate beds. The staff tend to sleep on the floor, on dirty mattresses if they are lucky, eating bug-infested food generously supplied by volunteers working in western Ukraine most of which I am told ends up being thrown away because by the time it arrives it is quite inedible due to infection and animal and insect infestations.
This is the reality of medical care on the front line in the principal war of the twenty-first century. Let us all be reminded of the horrors of war, and to stop fighting them.