‘We have a rule when we hear the sirens: if you've started operating, you don't stop': 24 hours with doctors on the Ukrainian frontline

The Guardian

22-02-2025

'The frontline here is cold, hard, true war. My comrades and I had more than 40 bombs dropped on us by drones over two hours. You can't hide from drones in a trench, but you can't outrun them either. Your only hope to live is to zigzag, to be cleverer than the drone.'
A gaunt 28-year-old former IT worker sits patiently beneath a window barricaded with sandbags, awaiting his turn on the operating table, cloaked in dust. Now an infantryman in the Ukrainian army's Third Assault Brigade, 'Sasha' (not his real name) has shrapnel embedded in his shoulder after the Russian assault on his foxhole. 'When you hear a drone, you run as fast as you can and see if you can reach any trees,' he says. 'If you're out in the open, you try to get the drone behind you, so it won't destroy your face. It's not panic, this running; it's a professional response. You know what you have to do to save your life and you do it.'
The war in Ukraine is dominated by drone use on an unprecedented scale. Some of the largest and most expensive drones in use are the winged Shahed attack devices bought by Russia from Iran, capable of flying more than 1,000km before smashing, kamikaze-style, into buildings. Much more common are the improvised drones that went for Sasha – tiny, adapted commercial quadcopters that used to be popular for filming weddings, yet which, once armed with explosives, become diminutive killing machines. Sasha made it to the trees, but not out of danger. He was hunted initially by nimble, first-person view devices controlled by operators using headsets and joysticks. These are usually aimed directly at their targets, killing them on impact, but they cannot follow fleeing troops through undergrowth. So Sasha's pursuers switched instead to higher altitude drones, armed with explosives, that can lock on to targets from above the tree line.
Having saved his own life by following his training and wrapping his limbs around a tree trunk, Sasha dismisses his injuries with a shrug. 'This is a scratch,' he says. It takes a young civilian paediatric surgeon turned frontline trauma surgeon over an hour to extract the metal embedded in Sasha's shoulder, using only a local anaesthetic as he burrows and probes. Sasha doesn't make a sound. Medical equipment for the army's walking wounded is often rudimentary. In this case, the surgeon resorts to a first world war technique of shrapnel extraction: inserting a magnet into the incision to drag the metal out. Even as his shoulder is being sutured shut, Sasha begins negotiating with the doctors to get back to his platoon without delay. Later, one of the doctors says to me, 'Infantry, these guys are the guts of war. They go into hell every day. I've seen guys injured for the tenth time and they still go back, because this is their land they are fighting for.'
For security reasons, I cannot reveal the precise location of this field hospital, a few kilometres from Ukraine's eastern front. Military medics and patients are regularly targeted by Russian forces, in violation of the Geneva conventions. I have travelled here with the Third Assault Brigade from Kharkiv – the country's second largest city, located just 30km from the border with Russia – to join combat medics for 24 hours. It has taken two overnight trains, a 4x4 and more than 48 hours to reach this point from the Polish border, 1,000km to the west. We crossed empty plains, blank horizons. There is little to check either tanks or troops on this bare, steamrollered land. 'Geographically, we are made for invasion,' observes my friend Andrii Myzak, a civilian neurosurgeon from Kyiv with whom I am travelling.
This is my fourth visit to Ukraine since Putin launched his full-scale invasion three years ago. As an NHS palliative care doctor, I have been supporting and helping train local hospice teams. The more I learn about the ferocious resolve of Ukrainian healthcare workers to keep looking after their patients, the greater my respect for their efforts and my desire to bear witness. Adult, paediatric and maternity hospitals have all been targeted, including, in July 2024, Ukraine's largest children's hospital, Okhmatdytin Kyiv, where a missile strike killed two members of staff. Last August, the World Heath Organization reported 1,940 confirmed attacks on Ukrainian healthcare, the highest number recorded in any humanitarian emergency globally to date.
For Andrii, 54, operating in Kyiv means balancing the risks of opening up a patient's skull with those of getting trapped above ground when a bombardment starts. 'We have a rule when we hear the sirens,' he says. 'If you've started, you don't stop, not once the patient is anaesthetised.' Every time Andrii and his team continue a neurosurgery during an air raid, they risk their own lives to save their patient. It sounds dauntingly selfless, yet for Andrii, it's still not enough. Last year he tried to join the Third Assault Brigade's company of combat medics. Its chief medical officer, Viktoriia Kovach, a 31-year-old former obstetrician from Kyiv, permitted Andrii to spend a few days working in a field hospital before telling him bluntly, 'Your skills are needed in Kyiv. I won't employ a doctor who can do more good in their specialty back home.'
By late afternoon, we finally reach the field hospital, an abandoned building in which a dozen doctors and nurses live and work together under fire. When not treating patients on operating tables and bloodstained stretchers, staff snatch rest on bunks in the basement, trying to ignore the sounds of battle above. There is an autoclave to sterilise instruments, a blood gas machine to analyse patients' biochemistry and portable freezers full of blood and plasma, 50 or so units of which are used every week. Dozens of similar 'stabilisation points' have been set up along the length of the front. They serve as critical first stops for wounded soldiers needing emergency treatment before being rushed onwards to major city hospitals for definitive care. About 30 wounded soldiers pass through this field hospital every day, but when the fighting intensifies that number can double or even triple.
For now, it's eerily quiet. Two wounded soldiers lie cocooned in foil to stave off hypothermia. A couple of doctors are slumped at desks. Hand-drawn pictures sent in by Ukrainian schoolchildren are taped to the walls to boost morale. 'Everyone is waiting for the grey zone,' explains Viktoriia, who inspires palpable respect and affection from those she commands. She is alluding to the devastating impact on combat medicine of drone warfare. Drones have rewritten the rulebook on battlefield survival. They prevent military medics from doing the one thing, above all else, that helps keep the injured alive: treating them as quickly as possible.
'When someone is hit, we can see them on the screen from our drones, but so can the Russians,' Viktoriia says. 'Our troops have to try to drag the casualty into cover, otherwise they'll be killed by drones. If a medical team tries to evacuate them, they will be hunted and killed, too.' The day's grey zones – the murky half-light of dawn and dusk – give medical evacuation teams the best chance of reaching the injured without being attacked. But too often, the density of drones along the front leaves casualties stranded in no man's land for hours or even days, with medics unable to reach them. Out here, there is no taking advantage of the 'golden hour' – the vital window in which trauma teams are most likely to save critically injured patients. Sometimes, they can only bear witness as a casualty slowly bleeds to death.
Night falls and still everything is quiet at the field hospital. Shortly before midnight, I'm escorted out into subzero temperatures and taken to an underground tactical command centre even closer to the front. Inside the concrete bunker are a dozen soldiers and, on trestle tables, a vast map of the local territory, the frontlines marked in black ink. Vlad, the head of reconnaissance, uses a wooden pointer to show the pinch points. It could be a scene from a second world war film, until you glance up at the banks of computer screens showing real-time drone footage of the Russian frontline. Vlad, 35, was a senior executive in a multinational IT company in Kyiv before he volunteered to fight. 'I brought some of our best coders to the brigade, too,' he says. 'This is a tech war and algorithms are key.' A kind of nerd war, then? He grins. 'Yes, down here it's a war of the nerds.'
Though the technology of killing has radically advanced, soldiers are dying just as they have for centuries. They bleed out. Their brains are battered. Organs fail. Vlad describes his team's efforts, earlier in the afternoon, to direct combat medics to a casualty with a traumatic pneumothorax – a lung punctured by shrapnel embedded in the soldier's chest wall. 'But no one with that has made it to the stabilisation point,' I say. We exchange glances. A pneumothorax is a life-threatening emergency. In the hours that drone fire has rendered him unreachable, the casualty may have died.
When we return to the field hospital, an operating room is in full swing. The patient with the pneumothorax has just arrived, caked in mud and blood. A vascular surgeon daubs his chest with coppery Betadine, to prevent infection. He takes his scalpel at speed through skin, fascia and pleural membrane, then directly into the lung itself. Swiftly he inserts a large-bore chest drain – a plastic tube the diameter of a small hosepipe. Blood and air start to bubble from the lung into a flask on the ground beside the surgeon's blood-soaked clogs. The soldier's oxygen saturations climb up. He is going to live.
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The casualties come thick and fast now. Three medevac ambulances arrive at once, each bearing two patients. So dishevelled and bone-weary are the combat medics, it's hard to distinguish them from the walking wounded. The two most seriously injured have life-threatening leg wounds from drone blasts. They are alive only because their comrades staunched major haemorrhages with military grade tourniquets. There's a catch, though. One of the men was pinned down on the battlefield by drones for 36 hours; the other, a 35-year-old called Mykola, for three days. To prevent bleeding out, a tourniquet must encircle a limb so tightly that the arteries are crushed flat against bone. After six hours, lack of oxygen begins to turn living flesh necrotic. Each man's injured leg is visibly swollen, deep purple and horribly misshapen. Amputation looks inevitable.
Mykola has lost much blood. An anaesthetist called Jenya administers drugs to keep him lightly unconscious while the team, working with wordless precision, cut off his clothes, wrap him in foil and insert a large line into his jugular to administer blood, plasma and antibiotics. You don't give up on a limb lightly. The surgeon makes a sweeping incision from knee to ankle to perform a last-ditch diagnostic fasciotomy. The procedure, exposing all the muscles surrounding the shin, allows him to directly apply an electrode to the muscles, searching for the tiniest flickers of life. Mykola's leg is entirely dead. Leaving the tourniquet on – it is too dangerous to remove it this close to the front – the surgeon packs the wound and bandages it shut. A nurse wraps Mykola in thick woollen jumpers, donated by local residents. Half-awake now, he struggles to raise his head, frantically trying to ascertain if he still possesses two legs. With gentle authority, Jenya presses Mykola back down. 'Easy, comrade. Easy.'
Just before an ambulance rushes him to Kharkiv for the amputation he doesn't yet know is coming, Mykola is able to tell me what happened. 'Three drones went for me. Two missed me and the third hit me. I was able to run into the trench and yell, 'My leg!' and then I lost consciousness. My comrades put the tourniquet on, but the drones trapped us in the trench for three days.' I ask what his hopes are. 'For my leg to be better as soon as possible, so I can come back here and fight again.'
Shortly before dawn, I talk with Jenya – who signed up to defend his parents and young daughter – about the impact of this work on his state of mind. 'I have very bad sleep. You have to be in a state of always being prepared, tense, always ready for action. I loved being an anaesthetist. When this is over, all I want is to sleep for a month and see my daughter.' He appeared sensitive and gentle when treating Mykola, but insists he feels nothing any more. 'I am quite introverted. I tried not to take all this pain inside myself, but it's such a struggle. In the early days I found it very hard to see so much suffering. Then I was sent to Bakhmut.' The frontline city was shelled so relentlessly that in 2023, President Zelenskyy told the G7 in Japan that its devastation reminded him a little of Hiroshima after the atomic bomb. 'Nothing alive is left,' he said simply. Jenya estimates that over nine months in Bakhmut, he treated between 6,000 and 7,000 civilian and military casualties, including children. 'Something died inside me. Too much horror. I stopped being able to feel,' he says.
He hesitates. Then, doctor to doctor, and with an expression that tells me he knows how wrong it is for a clinician to utter these words, he adds, 'I want to strangle Russians. They have brought so much suffering here, it is impossible to forgive. I have seen children die and doctors die and nurses die, so many friends die. I want to kill Russians.' Like many of the staff I speak to in the field hospital, Jenya worries that even if he survives the war, he will never be the same again. Three years in, Ukrainian combat medics are often taking antidepressants, receiving online therapy, fighting to sleep and experiencing traumatic flashbacks, all while continuing to work and knowing they are targets themselves. 'It is hard to keep on, but we will because we have no choice,' Jenya says. 'We are defending our homes, our land, our children. We can't stop.'
Where first names only are used, this is at the request of the individual, for security reasons. Readers can donate to Hospice Ukraine, the charity founded by Rachel Clarke and Henry Marsh to support local palliative care teams in Ukraine, here