'Pain will last a long time.' How surgeons save soldiers' lives after frontline injuries

After being injured at the front, not all military personnel immediately end up with neurosurgeons. Their help is needed when a complex surgery or something truly unique must be performed. Essentially, this is the last level of medicine, providing highly specialized care.

Neurosurgeon Oleksii Yeroshkin typically performs three surgeries a day during "calm" periods. However, more often than not, he spends the entire day in the operating room, from morning until late evening.

"As they say: war is the mother of surgery. Yesterday I left the operating room at 10:30 PM. Today, I’ve been at work since 7 AM. Right now, all Ukrainian medicine is firmly on military rails. Everything is being done for the military – the possible and the impossible," says the doctor.

The war is also changing medicine itself. Previously, injured soldiers were mostly sent abroad for rehabilitation, but now 90% of such recoveries are successfully carried out in Ukrainian medical institutions.

RBC-Ukraine spent several hours with the doctor during a military reception and shares how doctors are saving the health of defenders during the war.

'Got a shot of diclofenac and went on the offensive': How the health of soldiers suffers and what injuries are most common

According to neurosurgeon Oleksii Yeroskin, mine-explosive injuries are now the most common among all war wounds.

"These are mostly penetrating injuries to the head and spine. Less common are injuries to the arms and legs. Soldiers often have to be operated on after penetrating mine-explosive brain injuries. There are spinal cord injuries, which are the most severe of all. These are usually patients who will be severely disabled in the future. Especially considering that not everyone can fully recover from such injuries," he says.

How surgeons save the lives of soldiers after injuries on the front lines (youtube.com/RBC-Ukraine)

As soon as such a serious injury occurs, doctors must stabilize the defender as quickly as possible, preserving vital functions: breathing and heartbeat.

First aid is often provided by comrades or medics under shellfire, then the soldier is transported to a stabilization point. There, minor surgeries may be performed. But for most, this is only the first stage of long-term treatment, followed by rehabilitation. Then, the soldier is transported to the rear - to hospitals and clinics in Dnipro, Kharkiv, Kyiv, Lviv, and other cities.

Such injuries often require reconstructive surgery. Some need skull shape restoration if the injury has damaged the skull bones.

Many need to stabilize the spine with a special system if the injury has compromised the structural function of the spine. Recovery surgeries are also performed on peripheral nerves if the motor and sensory function of the limbs is lost.

Some narrow-specialized surgeries are simply impossible to perform in field conditions. Narrow-profile specialists often have to do cerebrospinal fluid shunting to stabilize intracranial pressure, or urgently perform a stabilization operation on one of the spine sections.

"Soldiers arrive in the 'acute period' to us. Sanitary evacuation is carried out. Both aircraft, trains, and cars are used. All those who need and can be transported are taken to specialized medical institutions. There, the highest level of medical care is provided. It’s simply impossible to perform such an operation at a stabilization point. And there may not always be a neurosurgeon there," explains the doctor.

Another problem is that during the war, soldiers' chronic illnesses flare up, even without injuries.

"Many men come to me with back pain and say: 'I've been getting diclofenac shots into my butt for six months, put on my bulletproof vest, and went on the offensive.' It helps up to a point, but later people are forced to seek help. This is not emergency care, but still," adds the neurosurgeon.

The spine and musculoskeletal system suffer the most. Constant overloading occurs in almost all soldiers, leading to continuous passive injury. Intervertebral hernias appear. Soldiers suffer from back and joint pain. Cardiovascular diseases flare up.

Photo: To bring a soldier for urgent surgery, a train, aircraft, or car is used

"There are also various psychological conditions. However, this is a background problem for all patients. Even civilians now require such psychological support," the doctor notes.

Soldiers are treated free of charge. In some cases, if the patient needs something unique, such as a stabilization system or something similar, even a private clinic covers part of the costs.

"De facto, all soldiers are covered by state insurance. If a member of the Armed Forces of Ukraine has a military service contract, they certainly have the full right to use all benefits for such medical services," the doctor adds.

How the war is changing Ukrainian medicine

There is an opinion that Ukrainian surgeons have already developed a unique experience in post-injury recovery, which is unparalleled by other doctors worldwide. Meanwhile, Yeroshkin believes that during the war, Ukrainian medicine is gaining strength, unfortunately, due to forced circumstances.

"Problems in medicine exist everywhere, even in well-developed and well-equipped Europe. This is confirmed by the feedback from those who have been there or who still live abroad and return here with their impressions," says Yeroshkin.

War exacerbates various problems, including those in healthcare. According to the doctor, it allows us to see weak spots and helps address issues. It also provides an impetus for change. If treatment is denied to a soldier, people quickly find out about it, and action is taken.

Previously, many soldiers were sent abroad for rehabilitation. Now, the doctor says, 90% of all recoveries - such as prosthetics, rehabilitation, and social adaptation - that were done outside the country at the beginning of the war, are now successfully carried out in Ukraine.

What soldiers are treated for in planned surgeries

Among Yeroskin's patients, there are defenders with chronic pain and issues exacerbated by injuries sustained during the war.

Valerii, a young infantryman from the 129th Brigade of the Territorial Defense Forces of Ukraine, underwent surgery yesterday on his neck and lower back.

"My back started hurting due to heavy loads. I went to the chief medical officer, who sent me for an MRI. The MRI revealed three or four hernias and seven protrusions. They said surgery would be necessary. I decided to find a good doctor to avoid having multiple surgeries and suffering, so I wouldn't end up disabled at 33," he shares.

Photo: For the defenders at the front, chronic problems are exacerbated by heavy loads

The soldier has two operated areas: his neck and lower back. To stabilize his condition, a cage was placed in his neck - an apparatus used to stabilize the spine after the damaged disc is removed. This is done to prevent nerve root compression and ensure proper fusion of the vertebrae.

"For an infantryman to sit in a trench, you first need to dig the trench. The bulletproof vest, ammo, everything is on you. Plus, you have to dig, carry sandbags, lay them, and then cover it all with rails and logs," Valerii describes.

The pain from carrying heavy loads starts mild enough to be managed with moderate painkillers. Over time, the symptoms worsen, and stronger painkillers are needed. Eventually, even those stop working, and the pain becomes constant - just as the neurosurgeon described for those who come for surgery.

Valerii realized at some point that he didn't want to end up in the ER. He began looking for ways to have surgery without missing his duties urgently.

To perform planned surgeries for soldiers, there is a paperwork procedure - following the official algorithm. Military commanders give the referrals.

"Since soldiers cannot move without official documents, they are simply referred to us," explains Oleksii Yeroshkin. This was the case for both Valerii and Vadym, a stormtrooper who is in the same ward. After receiving the referral, the men came for surgery.

On the day of the procedure, Valerii was initially very nervous. He lay on the table and thought, maybe the surgery wasn't even necessary anymore as the pain seemed to have subsided. "But then they gave me an injection, and that was it," the soldier laughs.

He also feared that something might go wrong during the surgery, making things worse. However, he was able to get out of bed and walk to the store the next morning. He even walked to the metro and sent his wife a detailed video on how to get to the hospital.

In the operating room, doctors may spend an entire day from 7 AM to 10 PM performing surgeries

Service in the infantry and threat from FPV drones

Serving in the infantry means doing everything, says Valerii. The infantry is when you build, sit at observation posts, and unfortunately, "take" everything that comes from the enemy.

"You know, I'm not surprised that not many people want to join the infantry. It's probably better to go into artillery or air defense. There, you're far away, and they don't shoot at you as often. But nothing can be done without infantry: a position is only considered ours where an infantryman stands," says the soldier.

Enemy FPV drones are "the most unpleasant thing." When soldiers hear their sound, they immediately identify whether it's their drone or the enemy's. Feeling safe in the open on the front lines is almost impossible, even with electronic warfare.

But the hardest thing for Valerii in the war is not the threat from enemy drones. The hardest part is being separated from his family.

"I'm a homebody, I miss my child and wife so much. WhatsApp doesn't replace face-to-face communication. I volunteered because I had to protect my family. In the first days of the invasion, there was a warning that the fighting could reach our city. Of course, I wasn't prepared. But I went to take up arms because you can't do anything at home with just a spoon and fork," says the defender.

To leave for an operation, someone has to take the place of the soldier temporarily absent.

"If I go, someone has to replace me. There’s a shortage of people right now. Every absence requires a replacement, and it becomes a problem. Recently, they added a few more people, so there was an opportunity to leave. I thought if I couldn’t go on sick leave, I’d have the surgery during my vacation," he adds.

Rebuilding damaged skull using a 3D printer

Before sending soldiers for rehabilitation, they first undergo several surgeries. It's rare for there to be just one procedure. Depending on the injury, a soldier may undergo more than 10 surgeries, and the process can take years. This is necessary to restore functions and anatomy where possible.

Ukrainian doctors have been actively using modern technologies in reconstructive surgeries for a long time. For example, stereolithographic models are used in skull plastic surgery after combat injuries.

Photo: Many skull injuries are being repaired using 3D printing

"First, we do a CT scan. This allows us to see the defect in the skull in detail. Then, using a 3D printer, we create an exact reconstruction of the damaged area, including the facial part of the skull. This allows us to plan the surgery on the anatomical model of the patient. These kinds of injuries are becoming more common, so this technique is highly relevant," says Yeroshkin.

After a severe head injury, the military undergoes a resective trepanation first, to stabilize intracranial pressure and remove bone fragments.

Once the wound heals, they perform skull plastic surgery, using titanium implants (meshes and plates that precisely match the shape of the defect). These are fixed with special micro screws, allowing the skull's appearance to be fully restored. The person can live fully without the limitations caused by the injury.

The implant itself can also be created with a 3D printer using titanium or formed directly during the operation from a plate that is molded to fit the defect.

"The first option is suitable for complicated cases, such as with the facial skull, whose configuration is complex and hard to restore anatomically during the surgery itself. In such cases, the 3D-printed implant is made in advance. If the defect is simpler, such as in the skull vault, the implant can be made during the surgery," the expert explains.

Such surgeries were not performed in Ukraine earlier. They began to be widely used around 10 years ago.

"In the current war conditions, innovative approaches have emerged, especially related to limb prosthetics. Soldiers are being fitted with stimulators for biometric and biomechanical prosthetics, which helps to better restore limb functions. These methods are actively evolving due to the war," says the doctor.

Military rehabilitation takes years

Mykhailo served in the 10th Separate Mountain Assault Brigade Edelweiss. This spring, he sustained a severe injury on the Bakhmut front. A shell from an RPG exploded just a meter away from him. His body armor and helmet saved his life during the blast injury, but the worst damage was to his arm.

Photo: A soldier is undergoing long rehabilitation after being injured near Bakhmut

The first surgery was performed just a kilometer from the front line, under fire. The blood circulation in his arm was restored. Otherwise, he says, they might have had to amputate it.

Since then, his arm has undergone nine surgeries. Mykhailo was treated in Dnipro, Lutsk, and Kyiv. He is now undergoing rehabilitation to restore function to his arm. Doctors say that there's still a long way to go before it works as it did before.

"There were numerous fractures, and they inserted metal plates in my elbow. After each surgery, there was a long healing period. The arm itself couldn’t move. There were contractures in the wrist, and the elbow also stopped bending. Due to nerve damage, starting from the elbow, I had no feeling in my arm," says the soldier.

A month after rehabilitation sessions, sensitivity in his arm partially returned. He can now hold light objects in his hand.

Rehabilitator Vladyslav Murduhov explains that the recovery process will be long and painful until the arm can fully function. Initially, it will be difficult to bend the arm, but over time it will get easier.

"When Mykhailo began rehabilitation, his range of motion was minimal, and the elbow almost didn’t bend. Now, it bends much better, and strength is gradually returning," explains Vladyslav.

One of the biggest issues in rehabilitation is contractures. They occur when a limb is left immobile for too long. After fractures, damage to ligaments or nerves changes the anatomy. The function of the arm is affected. The main goal is to help the patient feel like they did before the injury.

"The work of the rehabilitator is only 30-40% of the overall process. The rest is the patient's work. The patient must be ready for recovery and want to recover. If there's strength and motivation, the process can definitely go faster," says the doctor.

Photo: Most of the rehabilitation time is spent on the individual’s efforts and willpower

A long time ago, Oleksii Yeroshkin developed a series of exercises for patients who had suffered back injuries. It was quite a while ago, and the doctor was already working on other projects. One day, a man who seemed perfectly healthy came to see him.

"He told me: I had a stroke, I couldn’t move. Then I saw your series of exercises in the newspaper. I did them all, from the first to the tenth. And I fully recovered. It wasn’t the exercises that healed the patient, but his persistence. I give this example to all patients, not just soldiers. Quality rehabilitation and persistence in recovery give a 100% result – everyone’s result is different, but it gives results. The attitude to recovery is a must," emphasizes the doctor.

The person regularly performs the same exercises, and over time this leads to results. "You know, some people are disciplined and responsible about their routines. They’re ready to do the same thing for a long time. This brings results. And maybe there are other mechanisms in the body that we don’t know about," he says.

Oleksii is confident that young people who get injured at the front have a great physiological reserve for recovery and can fully adapt to life as it was before. Even with severe injuries and amputations, there is still a possibility for recovery and socialization.

"Don't lose heart. Life is one, so work hard on yourself and enjoy it. Even after serious injuries, it’s definitely possible to return to a full life, and it’s something that must be done," emphasizes the neurosurgeon.