'War Is a Trauma Epidemic,' Says Ukrainian Surgeon

LAS VEGAS -- The medical system in Ukraine continues to function pretty well in the face of the destruction wrought by Russia's February 2022 invasion, according to a top trauma physician from the country.

Even so, help from overseas is still desperately needed, said Oleksandr Rikhter, MD, who spoke at the American Academy of Orthopaedic Surgeons annual meeting.

Rikhter is president of Ukraine's AO Trauma chapter and has been working on the front lines since the first day of the invasion. He spoke for about 30 minutes to an overflow crowd about the situation in Ukraine, where bombardment across the country with rockets and missiles is a daily occurrence.

He was introduced by Col. (ret.) Roman Hayda, MD, who heads the orthopedic trauma program at Rhode Island Hospital in Providence. Of Ukrainian extraction himself, he is among a number of U.S.-based physicians who have gone to Ukraine to lend a hand and moral support.

But that's not the best way for American healthcare workers to help, Hayda said. He agreed with the U.S. State Department that it's too dangerous.

Demands for equipment and basic supplies such as dressings, sutures, and antibiotics remain great. But it also doesn't help for well-meaning foreigners to pack up random surplus equipment and supplies for shipment to Ukraine. Rikhter explained that these are more trouble than they're typically worth, since they may not meet the needs at the point of delivery. They have to be separated and redistributed, another costly burden for an already strained supply system.

Rikhter added that many medical supplies can be purchased locally and cheaply. Supply shipments from overseas donors make the most sense when the senders are in direct contact with recipients who can explain exactly what is wanted.

Much of the benefit from overseas support has been in the form of information and education. One of Rikhter's first actions after the invasion was to institute a series of webinars with colleagues around the world to share knowledge about battlefield trauma treatment. These "started within 24 hours of the invasion," he said, and over a 2-week period, developed into 27 Zoom sessions with 31 experts from eight countries -- a total of 40 hours of recorded material.

He and colleagues also collected a series of instructional videos, typically with English narration, and had them translated into Ukrainian. Since then, AO Trauma Ukraine has organized in-person seminars with some 300 participants thus far.

Rikhter also discussed the day-to-day lives of healthcare workers. Some of his review might sound familiar to American hospital staff who worked during the early days of the COVID-19 pandemic. Physicians, nurses, and staff worked around the clock. "You don't see the sun. You don't smell the flowers," he said. Hospitals have been "fully booked" since day one.

He showed a short video of his daughter, who looked to be 7 or 8, on the first day of the war sheltering in the family's basement. She was sent out of the country the next day. "I haven't seen my daughter since," he said, adding, "I am not sure we are still a family."

Burnout has thus become a problem, and especially so for orthopedic surgeons. Rikhter observed that in ordinary practice, a surgeon can see benefits for the patient almost immediately. But with victims of war, the doctor's job is often just to patch them up and send them somewhere else. Many don't survive that long.

And of course the situation in Ukraine is far worse than in New York City circa April 2020. Hospitals have been blown up and staff drafted into the army. Rikhter shared a photograph of a senior surgeon holding an assault rifle on a balcony alongside a uniformed soldier, participating in the hospital's defense.

Both Hayda and Rikhter pointed out that the limits of battlefield medicine mean that definitive treatment for survivors must wait for months. (Compound fractures, for example, are typically left in non- or malunion until external wounds heal.) Trauma physicians may simply perform vacuum-assisted closure on open wounds.

"Even if the war ended tomorrow," Hayda said, the demands on Ukraine's medical system will remain huge for a long time after. He also noted that the system still suffers from Soviet-era bureaucracy that discourages interdisciplinary teamwork.

Sending patients abroad for treatment isn't the solution for most cases. It's expensive and often leaves patients alone in a strange city, deprived of family support. But it was resorted to, especially early in the war, when hospitals in Ukraine filled up and staff weren't prepared with alternatives.

Indeed, Rikhter said, preparation is key in battlefield medicine. "War is a trauma epidemic," he noted, and as we all recently relearned, lack of preparation makes everything worse. It helps to have good stocks of supplies and equipment in working order. So does having reserves of space and personnel. But the most important component, he said, is education: a workforce at least somewhat familiar with the injuries inflicted in modern warfare.

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