With thousands of civilians killed since February in the Russian war on Ukraine, the Ukrainian people face one of the biggest challenges in their history. As officials and observers allege war crimes, we spoke with three on-the-ground physicians about what is happening, how emergency physicians there are coping, and what they need to survive.

Humanitarian Crisis

At the time of this printing, Russian troops had bombed 34 hospitals and medical facilities including the country’s biggest children’s hospital, Okhmatdit, a children’s onco-hematology and marrow transplantation center in Kyiv. Russian troops have shot at unarmed refugees and forbidden access to medics and rescue teams in occupied regions by shooting at them without warning, according to Anton Volosovets, MD, Dr. Sc., head of the department of emergency medicine at Shupyk National Healthcare University of Ukraine in Kyiv.

“People in occupied regions are without food, electricity, and gas, which leads to humanitarian catastrophe,” Dr. Volosovets says. “Children are dying without receiving basic life support. From the beginning of the war, we know of about 38 murdered children and 71 children who were wounded.”

ACEP Liaison Vitaliy Krylyuk, MD, a surgeon and emergency physician at the Ukrainian Scientific and Practical Center of Emergency and Disaster Medicine, a division of Ukraine’s Ministry of Healthcare in Kyiv, says what is going on is not a military operation, but terrorism. “It’s like World War III,” he says. “They [the Russians] absolutely don’t have any humanitarian principles.”

On March 1, ACEP released the following statement commending the bravery and steadfast commitment of emergency physicians currently treating patients in Ukraine.

“ACEP proudly supports the emergency physician colleagues currently working in Ukraine,” said Gillian Schmitz, MD, FACEP, president of ACEP. “Emergency physicians across the world make a promise to treat anyone, anytime, and that means during conflict, disaster, pandemic, or any other difficult time. ACEP members are courageously rising to meet the moment and treat patients under extraordinary circumstances and incredible duress.”

Brian R. McMurray, MD, FACEP, an attending physician at Vanderbilt University School of Medicine and ACEP’s Lead Ambassador to Ukraine, has been to Ukraine more than 40 times. We spoke with him via Zoom when he was in a location near the Moldovan border, working with local officials to set up deliveries of humanitarian supplies. Long-time friends with Dr. Krylyuk, McMurray says he wishes he could be with his colleague in Kyiv, but the corridors used for getting in and out of the city are not safe. That evening, he met a couple of families in the border town where he is staying; they had evacuated through one of these corridors after spending 12 days in their basement. “They finally couldn’t stand it anymore,” he says. “They just got to the Moldovan border earlier today, dropped off their wives and kids and are headed back to the battle ground. That is a microcosm of Ukraine today.” He added that men who are 18 to 60 years old in Ukraine are required to serve in the war unless they have three children or more, and that even if it weren’t required, they want to fight for their country.

“I came here for my first visit in 1996,” McMurray says, “Five years into their separation from the Soviet Union. Now they know freedom and they’re not about to become a Soviet puppet republic ever again.”

Coping

Ukrainians are undergoing great stress, fear, anger, pain, hatred, and despair, says Dr. Volosovets. For health care workers who remained in Ukraine, there are long hospital shifts amidst a fear for the safety of their own families. There is constant doomscrolling online for news about the war and its victims and a feeling of uncertainty for the future.

“All these factors simply crush your nervous system and deplete its reserves,” he says. “I was trained to keep my mind calm and logical even in the most harsh situations.”

This knowledge also helps Dr. Volosovets treat patients and help colleagues, relatives, and friends by teaching them relaxation techniques, breathing exercises and special physical exercises to remain calm. “But the best treatment from anxiety and fear is work,” he says. “Work that helps my people. Work that helps my country and makes our common victory closer.”

In Kyiv, emergency physicians are seeing polytrauma, gunshot patients, brain concussions and other injuries. They are also seeing cases like heart attacks and strokes. For triage, Dr. Volosovets and his colleagues are using the standard M.A.R.C.H. approach (Massive hemorrhage, Airway, Respirations, Circulation, Head injury/Hypothermia) with further evacuation to hospitals with proper specialization, when possible, by ambulance or in the case of non-urgent injuries with the help of military or civilian transport.

However, there are great problems with transportation logistics inside towns due to the descruction of bridges and buildings. “Our ambulances are suffering most because of it,” Dr. Volosovets says. “Also, it appears that hospitals and doctors are a favorite target for Russians. They are intentionally bombarding our hospitals, killing our doctors and shooting at ambulances. The sign of a red cross has been turned into a target.”

Nonetheless, Ukrainian doctors remain true to their commitment to treat all injured people, including Russian soldiers. “They have received proper treatment in our war hospitals alongside our soldiers,” Dr. Volosovets says. “We do not make any difference between our patients.” He added that the question of judgment for war crimes is not a doctor’s jurisdiction and although the Russians are not respecting international laws of war and the Geneva Convention, Ukrainian doctors remain bound to these laws and medical ethics.

While some of Dr. Volosovets’ colleagues have sent their spouses and children to safer parts of the country or to neighboring countries, he and his family have decided to remain in Kyiv. Dr. Krylyuk’s parents, grandparents, sister, and nephew evacuated to western Ukraine near the Romanian border. “I feel very calm because I know my family is absolutely safe now,” he says.

When there are large numbers of patients at the hospital, both Dr. Volosovets, Dr. Krylyuk, and their colleagues remain at the hospital overnight. Sometimes it’s difficult to get home due to transportation logistics or bombings. One gynecologist at Volosovet’s hospital remains there around the clock due to the risk of premature deliveries.

“Some of my colleagues even take their families with them to the hospital and simply live there alongside patients. They think that it would be safer—hoping that Russians won’t shoot missiles in hospitals. Reality is quite the opposite, as we can see,” Dr. Volosovets says.

Protocols

After so many years, emergency medicine in Ukraine has had to catch up to emergency medicine in U.S. Dr. Krylyuk says their triage system was not set up for mass casualties. “We just started to organize the triage system in our civilian hospital because this situation was completely unexpected,” he says. “It was unimaginable.”

We spoke with Dr. Krylyuk on March 10 at a time when there was a lull in the fighting in Kyiv, with Ukrainians holding back Russian troops. He and his colleagues were spending their time preparing for the possibility of mass casualties and working out the logistics and protocols to put in place that would involve alternate ambulance routes to the hospital, number of stretchers needed, record-keeping for unknown patients, and color coding for triage. The system is based on international protocol and assisted by Dr. Krylyuk’s multiple visits to the U.S. in the past (where he attended ACEP’s scientific meetings) as well as his visits to Canada, Israel, and western Europe. “I have taken many courses and imagined how to create this and organize a system,” he says. Dr. Krylyuk has created protocol documents that he says might ordinarily take a year to get the stamp of approval from the government. With the urgency of the current situation, however, that approval was granted in days. Now, for example, instead of it taking 20–30 minutes to send a patient to several different buildings for a transfusion, blood is available in the operating room and other places in the hospital where it may be needed immediately.

Supplies and Donations to Hospitals

Blood supply is currently plentiful in Kyiv. Dr. Volosovets says he is proud of his people; in the first days of the war, they received so much donor blood that for the first time in his memory their blood banks were overfilled. “We are all trying to do our best now,” he said. They do need medical supplies, medication, equipment, and combat med kits, however.

Renée Bacher is a freelance medical writer located Baton Rouge, Louisiana.