一线医务人员的自白

![](/media/202412//1733470880.3738005.png)“那并不是看到血的景象 让你害怕的是可能的

犯错误。承认

一线医务人员

![](/media/202412//1733470880.3917935.png)***Читать*** ***на*** ***русском*** ***языке***

“你已经习惯了士兵们的伤口，但是 一看到受伤的孩子们就会被扔出去 你离开。“乌克兰人

战斗医务人员

我是一名战斗医生 。当ATO开始时，我参军并参加了战斗 那里是一门战术医学课程。在全面入侵期间，我是

与一群志愿者一起参与了疏散平民的工作 。它

这一切都始于我的一位前同事需要撤离他的家人时

来自切尔尼希夫的家人 。我们找到了一条相对安全的路线

设法疏散了他们。Word传播迅速 ，人们开始传播 打电话给我寻求帮助。后来我们收到了一个请求 他们疏散了一家婴儿被遗弃的妇产医院

需要特殊的照顾，而没有办法提供它 ，这个城市是

在大规模的炮击。我们得到了一辆重症监护车 ，之后 我们成功疏散提供保留车辆 。的请求

帮助并没有停止，考虑到我们的小组包括了很多人

与军事医学有关的人，我们决定认真对待 关于在前线营救伤员的事。

![](/media/202412//1733470880.408161.jpeg)

Alexei，战斗医生

我们有几个由医生和护理人员组成的团队 ，其中大多数都是

愿意在业余时间和我一起旅行。有一个团队来自美国 扎波里日齐亚第五医院 ，他们换班，腾出10到14天

一段时间除了医生之外 ，这个团队里还有志愿者。为了

例如 ，我们现在有来自瑞典的护理人员与我们合作 。那里 是我们作为特殊单位的一部分去热点的时候。为

过去四个月，我们一直在帮助稳定站 巴赫穆特河

*医院的医生换班有空10-14天* *请前往“前线”*

我们有一个专门的平台供我们使用 一辆救护车 作为一个有轮子的手术室，还有一个重症护理车 允许我们执行所谓的战术疏散。取决于

在位置上 ，疏散链可能会有所不同。有时我们拿一个 受伤的人 ，给他进行急救，并带他稳定下来

医务人员为他工作的地方。有时我们自己也扮演角色 在一个稳定站的医务人员。

如果受伤的人胸部受伤而不是简单的弹片

伤口和需要特殊护理，如引流或输血 ，我们

带他超越巴赫穆特 ，到克拉马托尔斯克或德鲁日基夫卡 ，表演

在路上进行了所有需要的操作。例如 ，当血液 需要在道路上取样 ，我们示意司机开车变慢。

毕竟 ，这不是一个普通的塑料管静脉注射 ，而是一个程序

使用一根铁针 ，如果你把它在针可以 破坏血管 ，但如果战术形势允许的话

没有炮击 ，我倾向于提供最大数量的援助

现货 ，因为病人得救的机会降低了 指数随着时间的推移。

每次旅行都是特别的，每次都有新的事情发生 。二

几个月前 ，在巴赫穆特 ，我们是唯一能提供全额服务的人

医疗护理 ，因为当地的第93旅只有警卫室 救护车，整个医院只有一台超声波机，

包括两个手术室。

*当地的救护车队在车里只有四轮马车，还有一个* *为整个医院的超声波机*

我们有一组医生按照损害控制部门工作

手术协议 ，一种在美国学到的野外手术战术

国家这种格式也被称为SOST -特殊手术-外科手术

团队 。当我们和这样的团队一起旅行时，我协助手术-我的 资格证书不允许我进行外科手术干预：我可以

进行气管插管或输血，但我不能进行 例如开胸手术。

![](/media/202412//1733470880.438177.jpeg)

在十分之九的案件中，我们处理了地雷爆炸的后果

创伤患者可分为三类。第一个是那些确实是这样的人 反正他们也会死的 ，因为他们的伤是不相容的

与生活。通常情况下，你会开始治疗这些受伤的人 在这个过程中 ，你已经意识到病人无法被拯救。

例如 ，你看到一个肢体的大出血 ，然后你取

从头盔上看到另一个弹片缠绕在头盔下面 ，还有

你对此都无能为力 。第二个人是那些幸存下来的人

不管怎样 ，即使我们不去接它们 。幸存者的统计数据大多是 基于他们 ，尽管即使没有我们，他们也能活下来。

第三种是那些人的生命完全依赖于他们的行为

医务人员 ，这一组是最困难的，统计数据非常糟糕， 不幸的是 ，现在还没有与他们合作的好方法。

外出血是导致死亡的常见原因之一，也就是说， 四肢出血 ，这很容易停止。这是第八个

在大多数情况下，我们有些人不知道该怎么做 使用止血带<的临时止血装置

内部>。处理一个小的伤口是很常见的

止血带不需要止血带，但已经安装，拧紧 ，离开6分钟 不管怎样的时间。结果 ，一个士兵可能会回到

三周后的任务最终被截肢。反之亦然

止血带没有安装，我们有一具尸体已经流血了

出局如果提供急救的人没有胜任

足够了，它可能以死亡或悲剧告终。

*通常四肢需要截肢，因为如何正确地止血* *许多* *不知道*

另一个原因是 ，90%的病例会导致致命的结果 巨大的内出血 。它可以通过跟踪损坏来防止

控制手术协议 ，这里很少有人知道。这似乎是一个

简单的程序：打开和放置钳 ，在大多数情况下胶带和

冲去医院 ，但我们一直把他从一个稳定下来 直到他遭受失血性休克 。在大多数情况下 ， 运送受伤人员的首席医务官，

认为晶体结构(例如 ，廉价的盐水溶液，

生理上的解决方案)是一件好事，如果有大量的血液 需要注射林格溶液 ，同时干燥

等离子体是黑色的魔法 。但事实上，干性等离子体可以在 字段 。在发生大量失血的情况下 ，它可以补充大量的血液 血量我们在重症监护室中储存了一些干燥的血浆

但两个月前，其中一辆被火箭击中了 另一个则在氧气罐引爆时爆炸了。

有一天，我们接待了一个受伤的人，根据所有的情况

文件 ，受了轻伤。他的腹部没有穿透性

一块弹片切掉了一块皮肤，还有他的伤口 情况被归类为声气压损伤

耳朵但当我们把他装进车里 ，绑住他的时候

我们发现他因髋部骨折而发生了失血性休克。A

髋部骨折是非常隐匿的 ，最初很难发现

检查 ，它充满了大量的内部失血：高达

两升的血液可以进入肌肉，这就是为什么

引起出血性休克。在注意到这一点后 ，我们开始重新评估 对于患者 ，我们确定了骨折 ，进行了骨牵引，然后

只是因为我们身边有干血浆 ，我们才设法让他活了下来 直到我们到达医院 ，他才活了下来。如果是93号的船员

那天值班的旅是代替我们来的 这肯定是一个致命的结果。

我们的工作大多是困难和不可预测的 ，你会习惯的，

但总有一些事情是你不能习惯的 。在我们的最后一次旅行中 城市遭到猛烈的炮火，俄罗斯军队击中了一间公寓

建筑我们的男人把一个三岁的女孩从大楼里拉了出来；她 有与生命不相容的伤害 。她死在了我们的桌子上。和

当你很快就习惯了军事伤害 ，儿童的伤害

把你扔掉 。孩子们是这个故事中最困难的部分 ，因为因为 未知的原因，他们仍然留在城市里，而当你看到贝壳-

震惊的孩子们在街上玩耍，这很好，有点难。. . .

*我们把一个三岁的女孩从大楼里拉了出来；她受伤了* *这与生活不相容，她就死在了我们的桌子上*

就像我2014年第一次战斗一样 ，我第一次看到受伤

然后他昏倒了 。事实证明，这是一种相当常见的现象 反应直到我的搭档打了我一巴掌 ，我才明白了

出行但后来，当你发现自己更加平静时，情况就变得更困难了

情况如何 ，并能够反思每件事情 。然后它变成 可怕的是：你会意识到有一千种可能的方法

情况还会发展 ，情况可能会更糟。

“医护人员会做疯狂的事情，药物存在 供应不足，这导致了巨大的供应不足 可预防的损失。“N。，一个俄罗斯人 intensivist

我自己也没有去过前线 ，也没有去过有工作的俄罗斯医生

在前线是被严格禁止与记者交谈的，所以他们

我不太可能和你说话。但我经常和军事医生交谈 去前线，他们详细地谈论了他们的工作和

给我看照片。他们对医疗设备非常挑剔

医生和护理人员——一切都过时了 ，一切都过时了 供应 ，而且几乎没有向人民提供培训

谁在那里工作 ，所以可预防的损失非常高：大约30%

谁会死于俄罗斯方面的伤口 ，谁会死于非致命的伤口

（相比之下，乌克兰方面的这个数字是5%）。也就是说 有时 ，用一个正常的止血带就足以防止a

人从死亡 ，但要么没有正常的止血带 ，要么在那里 装备里根本没有止血带 ，或者没有足够的急救箱， 或者一切都有 ，但医护人员没有受过训练——最终

有大量可以预防的伤亡。

这个工具包中主要缺少的是良好的止血效果

布料伤口上有一些特殊的物质， 止血的止血剂 ，良好的止血带和

压力敷，但不是俄罗斯制造的就是中国制造的

工作得很差，而乌克兰人有高质量的东西 ，所以 俄罗斯军人在有机会服用时非常高兴

来自受伤或死亡的乌克兰士兵的急救箱和抢夺

他们所提供的一切 。我们的医生有的最好的东西是 他们设法从乌克兰人那里偷来的东西。

乌克兰人有组织良好的护理人员来接他们 伤员 ，用止血带，止血带去

在他们可以得到帮助的地方 。他们确实已经停止了放置 医生在疏散车辆上 ，只有经过培训的非医务人员

-因为他们的疏散车辆是我们军队的目标。

他们非常喜欢完成它们 ，因为通常会有一个很大的 每一辆这样的车上的士兵人数。杀人是一种战争罪 受伤的撤离者 ，当然没有人会这样说

记录但我认识的一位医生很自豪地告诉我 ，那些车辆正在行驶

“迅速被惩罚和摧毁 。”“他们甚至都不隐藏它，他们是这样的

为此感到骄傲——如果他们看到一辆载有乌克兰人受伤的疏散车辆， 他们试图摧毁他们。

*俄罗斯军人自豪地告诉他们是如何射击的* *乌克兰的医疗车辆，尽管这是一种战争罪*

军医有几个级别 医疗单位 ，医疗排，

医院首先 ，他们在战场上做了一些关键的事情，

然后 ，在可能的情况下 ，他们把伤员带到一个或多或少安全的地方 他们可以得到帮助 ，然后他们把他们带到医疗单位 ，在那里只有

医生在工作，然后 ，当大量人受伤时 例如 ，他们将他们疏散到最近的医院，

在罗斯托夫或贝尔戈罗德。那些伤势较重的人将被送往莫斯科

和圣 。彼得斯堡许多医生已经被动员起来了。动员的 医生们尽力去医院执行任务 。他们中的大多数人没有 我想在战场上工作。

一般来说 ，对地面医生的培训水平相当差， 但当局不能派出优秀的 、经验丰富的军医

因为他们在工作地点有巨大的工作负载，所以最多 合格的人会留在莫斯科和圣 。彼得斯堡当局保持

派训练无素的医生 ，他们一件事都做不了 ，因此大量 生命和肢体的损失 ，如果有医疗护理 ，就可以预防了 是正确的组织 。我的一个熟人看了一段视频

乌克兰的医生在工作 他们是如此的专业 ，很明显他们 他们得到了美国或以色列的指示

被训练去遵守他们的协议。他们有协议 训练自动遵循：采取措施防止

重伤士兵迅速死亡 ，止血和

避免出现可能导致士兵在其内部死亡的危及生命的情况 接下来的几分钟或几个小时 ，然后把受伤的士兵送进去 病情被送往一家有高水平医务人员的医院 。它只需要

简单的执行一个算法和良好的可用性

消费品你可以看到 ，乌克兰方面拥有一切和其他国家的一切

他们接受过训练，因为我怀疑他们知道怎么做 头名非常好的培训。

*俄罗斯医护人员没有准备，做一些疯狂的事情* *乌克兰的医务人员根据西方的协议，他们有* *显然训练得很好*

和我交谈过的医生都有武器 。他们不战斗 ，他们携带枪支

以防万一他们可以使用枪支 ，直到需要使用 伤兵我在和平时期的一个熟人是个儿科医生 在一家普通儿童医院工作的重症监护医生

莫斯科一些爱国情绪开始了 ，他决定去玩

在战争中 ，他竟然成了一名志愿者。这甚至都不是钱的问题， 他就是非常喜欢它 。他大约45岁了 ，他被洗脑了，

他告诉你“嘘 ”和“粉红 ” <贬义词

乌克兰人和美国人的>应该被杀 ，然后他带给你看 乌克兰方面一切组织得如何的视频

我们这边的一切是多么糟糕 。如果你问他为什么我们应该这样做 把俄罗斯世界带到乌克兰，而不是反之，他已经准备好了

马上回答： “他们做得很好 ，因为他们已经在准备了 为八年的战争 ，不像我们。我们不知道我们要去了

到战争。“他在医学方面很专业，但绝对如此

对战争的话题被洗脑了 。总的来说，那些和我在一起的人

说话是悲观的 ，但不是在我们将会失去的意义上，而是在美国 感觉战争将会很长 。他们如何心理应对

发生了什么，我不知道确切 ，但我的熟人看起来 就好像他经常喝酒一样 。”

“在被包围后，我们不得不这么做 获得射击技能。“卡的

加卢什卡，乌克兰护理人员

我是一名东方历史学家 ，但在2019年，我决定这么做

为了胜利 ，我为自己找到了辅助医疗服务 。我拿了一个 在“医院 ” 志愿医疗营成为

它的一部分。在那之后 ，我开始了我作为一名军队去顿巴斯的旅行 护理人员

我们在第一行上旋转，我们称之为“ 归零地 ” 。“它是

与战场上的所有战壕位置相等距 。你在值班

轮换时是24胜7负。如果你睡着了 ，你就会醒来 ，去捡东西 受伤的人 。旋转本身可以持续两周以上

![](/media/202412//1733470880.4667945.jpeg)卡特琳娜 ，护理人员

根据三月和TC3协议 ，我们不应该首先提供 在战场上的援助，因为它危及双方的生命 医护人员和伤员。因此 ，最大值可以是

在战壕里做的就是把止血带放在一个人的四肢上 快速地把它们装到车上 。当车辆在移动时

到疏散的第二阶段 ，我们提供一切必要的援助： 停止大出血，确保正常呼吸 ，空气循环，交易

对于任何需要手术干预的复杂损伤，请稳定下来 伤者 ，也就是给抗生素 ，止痛药和

沏或泡成的浸液

我们通常会在炮击开始之前很快地完成所有任务。我们

可以在猛烈的炮击下工作，但我们需要远离火灾，

特别是从小口径的枪，如机关枪和攻击枪 步枪总是由护理小组指挥官来决定是否

在猛烈的炮火下接一名受伤的士兵。有时我们 不允许去或者我自己决定不去

我理解我不能让其他团队成员的生命处于危险之中 。I 可以冒自己的生命危险 ，但不能冒别人的生命。

![](/media/202412//1733470880.5050578.jpeg)

战争表明 ，即使是医疗人员也需要知道如何处理 武器起初 ，我们的营长们对此并不满意，

但在医生被包围的马里乌波尔之后，我们中的许多人

学习了基本的射击技巧——因为你永远不知道什么可能会发生

以及这些技能可能需要的地方。我也做了特别的 每月在射击场练习一次。

当你看到有人受伤时，而不是看到流血或受伤

这让你感到害怕，而是一想到你可能无法应付。

即使三年过去了，我仍然担心我可能做得不够 ，但是 幸运的是 ，没有人死在我的手里 。在治疗我的第一个 一名受伤的士兵，我非常担心我可能无法收紧止血带 或者用正确的方法包扎伤口 。这其中最重要的一点是 情况是要记住一个人的生活在你手中 ，它

这取决于你，他们是否能回家。我总是尝试 保持冷静 ，坚持规矩，说服自己我做得最好 我可以。

*当你看到一个受伤的人，它不是看到血或*

*让你害怕的，是你可能不能* *应付*

在3月5日之前，我只是按照我应该做的那样做了我的工作 ，但它没有

对我的心理状态产生影响，但后来，当我所爱的男人 死了 ，我很难看到一个人受伤了 ，更不用说被杀了 。 最重要的是，我一直在经历很多让我感到震惊的事情 没有时间去反思。

当我看到一个死去的人时，我总是认为我所爱的那个人是谁

可能也是那样撒谎 ，或者是我身边的人，他也在 现在的战争，也可能会受伤 。有时是心理上的

很难忍受 。至于伤员，我很难和他们一起工作，

还有：我担心他们 ，我想让他们生存下来 ，因为我知道是什么

这就像失去了一个人，所以我很紧张 。但我总是努力做到 还记得我为什么进入这个在一开始。

*当我看到一个死去的人时，我总是认为我所爱的那个人是谁* *可能也是这样撒谎，我试图尽我所能拯救所有人*

从全面入侵开始以来，我就一直在一个地区工作

防御行动 ，而不是进攻行动 ，这就是为什么弹片

迫击炮和大炮造成的伤口是我大多数人要处理的问题 案例我没有遇到很多枪伤，只有四处 ，但它们确实是 最难治疗的。最近有很多人受伤了，

特别是那些踩上杀伤人员的“花瓣 ”地雷的人 。他们是

这是很危险的 ，因为它们是看不见的 ，并且很好地融入了其中 环境“花瓣 ”矿通常散布在草地上或草地

在城市环境中 ，当一个士兵踏上这样的矿井时 ，它就会消失 要么撕掉他的脚，要么严重受伤。

![](/media/202412//1733470880.5186524.jpeg)

杀伤人员爆炸地雷（PFM1）也被称为“花瓣 ”

矛盾的是 ，我觉得在工作中比在家里更安全。当我在一个 如果有危险，总有人值班警告我，

当我休假的时候，我可能不会听到空袭的声音 其中一个人会拿着突击步枪站在我旁边。

“这些人不明白为什么他们会这样做 没有死，更重要的是，为什么

他们根本就在那里。“K。，一个俄罗斯人

军医

我这辈子都在当军医，现在发生了什么

不会吓唬我——这不是我生命中的第一次

我见过伤员。这是我的工作 ，就像其他医生一样， 只是有点不同 。唯一的区别是在和平时期

受伤更少 ，现在更多，但我不能具体

我也不能谈论我对来自美国的军人的工作

乌克兰-我签署了相关文件。

我尽量不去想战争 ，因为如果我开始命名最近的战争 这样一来 ，我就必须对它做出评估，采取一种立场，

但我不能采取任何立场 。作为一名外科医生，我的职责首先是为了省钱

人们 ，为了尽可能多地拯救他们 ，不要去思考谁是对的 ，谁是对的 我错了，谁该为正在发生的事情负责 。另外，你知道很多

我需要坚持什么职位。这不是关于 医学

当你遇到你生命中第一个受伤的人时 ，你会很害怕 ，但是 不是血(我几乎不会上医学院

害怕血的)；你害怕不能做出正确的决定 决定 ，你不会希望别人因为你的错而死。

从心理上讲，这很难，但我们已经被教导了，或者我们自己学会了， 来应对它。

我们现在要处理的是各种都可能的教科书式的案例

在军事外科中发现：各种软组织损伤 ，骨折，

截肢 ，不同性质和程度的弹片伤 。这一切

这取决于谁被带到我们这里的，那个人是否在 我的或遭到了攻击。

![](/media/202412//1733470880.531158.jpeg)

那些工作过的专家们都犯了很多错误 在我们面前，显然没有被派到前线

训练——在接受了他们的治疗后 ，病人往往会失去四肢，

这并不是最糟糕的事情 。我看到了这些混乱 经常 ，我意识到如果伤者被治疗

作为一个更能干的专家 ，他很可能会保留自己的肢体。I

知道谁被送到前线 ，有一个大医疗 社区和医生相互分享信息。当你

听说一个刚毕业的专家被派到前线

大学毕业或者还没毕业 ，你明白什么会

事情会发生在他未来的病人身上 。通常，就连我们也无法拯救a 耐心地说 ，尽管我们不是在前线 ，而且可以

提供适当的护理。总的来说 ，我们的医院 ，尽管有

专家的培训水平，结果还没有准备好接受 伤员大量涌入 ，并经常在这种情况下工作 根本没有必要的设备来进行研究。

*我们的医院还没有准备好迎接大量涌入的伤员*

很多伤员都被带了进来 ，而且他们通常都是年轻人 谁还没有时间活着 ，但已经残疾 ，没有准备好

因为所发生的事情 ，并被内部打破。我已经看过很多电影了 最近那些空眼睛——家伙不明白他们为什么还活着，为什么 他们没有死，最重要的是，他们为什么会在那里。

“有时我们工作时没有灯， 发电机仅用于运行

房间和ICU。“p.”，一个乌克兰人

军医

战前 ，我在联合部队的一家流动医院服役 在顿巴斯手术区两年，我不能离开

复合时间超过15分钟 ，因为在任何时候都是a 伤员可以被带进来 。条件几乎是

和现在一样，唯一的区别是有一千个 受伤次数减少。

看着它们总是很可怕的 ，尽管恐惧的概念是

与医学不相容 。我们特别担心病人

当有不寻常的情况 ，很难决定做什么

离开但是 ，幸运的是，我们并不是独自工作的：有一整个团队 医院的专家，其中一些人有20-25年的经验

有军事医学或外科手术方面的经验。就我个人而言 ，我治疗伤口 使用外固定装置和截肢 ，但我也可以帮助

其他专业的外科医生，如果需要的话 。理解它是很重要的

我们提供全面的专业护理，但并不高 专门的，因为伤员随后被带到大城市 为进一步的综合治疗。

70%的伤口与软组织相关，这个数字与

第二次世界大战的统计数据；其中一些是枪击骨折

骨头，大小。伤口的性质在很大程度上取决于此病

无论是炮火、火箭弹攻击、空袭、地雷还是小型攻击

对他们发动了武器射击。重要的是那种炸药 被用于矿山。

一个受伤的人身上可能有一个巨大的弹片

不影响重要器官的身体，或者他可能遭受小 伤口，一些重要器官受伤。例如，一个病人

没有重大的受伤，只有一个小的弹片伤在肩膀上吗 对肱动脉的损伤。这样的伤害，如果不及时治疗

方式，可能导致截肢或严重失血，

造成休克和死亡。只有十分钟的时间来申请a 止血带

*使用止血带* *臂动脉损伤*

在病人去医院之前，其他医生会为他工作。这是一个 要困难得多。如果我们的情况比较平静，院前医生会 把伤员赶出战场，并迅速进行管理

急救有时会发生，一个受伤的军人不能

由于长时间的炮击，提取了几天，当每个人都是

在敌人的火力下，医护人员需要确保他能找到我们

而且不会死。这就是为什么我们的死亡率是最低的：这一切取决而定 希望在前线及时采取行动。

几天前，我们不得不在停电期间工作，因为有很多人 来的病人。对于这种情况，我们医院有一个发电机， 它服务于手术室和重症监护室。但只有10个

15%的伤者需要做手术，其余的则被送往伤口

更衣室或防震室。当实际上没有时

照明，在那些房间工作。也有很大的 分诊阶段的问题：有必要分离严重

受了轻伤，没有遗漏任何伤口

并不清晰可见，一个入口伤口的大小可以小到 一毫米。

*没有光的时候工作很难。有时是毫米大小的入口* *你* *必须看*

*伤口*

有很多人受伤，但你会记住其中的一些

时间很长，不是因为他们的伤口很严重，而是因为

他们的具体故事。我有一个来自米科莱夫的病人。当他服役的时候

在卢甘斯克地区，他的女儿被杀了。另一个来自 利沃夫，他在战前当过园丁，后来去了前线

没有任何经验。他有一双如此善良的眼睛。战争夺人

远离和平的生活，迫使他们拿起武器。

我从穿他们的衣服身上听到了很多轻伤病人的故事

或者在手术前和他们说话。他们告诉我现在是什么情况

在前线，就像，他们来自哪里。大多数受伤的我 记住截肢者。这些大多是创伤性截肢手术，

当一块弹片切掉一只脚，一只手臂，一只手，一只前臂或一只 臀部我们很难忘记这样的病人，因为他们都是年轻人

他们本应该一直享受他们的生活，努力工作和参加体育运动。 但当他们失去了一根肢体时，悲剧就会进入他们的生活。

根据他们服役的单位和年龄，他们要应付它 不同的方式。职业军人知道他们还活着

他们将能够参加体育运动，甚至为a服务

假肢，而新兵和平民都不相信他们能应付好；

这对这些病人来说在心理上是非常困难的。我最近有一个

受伤的人，有一只脚附在腿上的皮肤和两个

肌腱。在手术前，脚被切断了，因为它更容易

把病人往那边移动。这几乎已经是一个完全的创伤了 截肢而不重建动脉和骨骼

发生是由于巨大的组织损伤，永远不会愈合。

大约70%的病人已经失去了一根肢体并理解了他们

将会没有一个。与此同时，他们也没有感到痛苦，因为 他们处于严重的镇静状态，可能处于休克状态，但不是

因为肢体受伤，但也因为大量的失血。我们的目标 这样的损伤是为了尽可能地保存组织

我们可以在未来加强它，使一个良好的残肢适合

进入假肢的牙窝。有些情况下，即使是在我们的研究结果之后

帮助时，因为巨大的骨头或软，仍然需要截肢

组织缺陷、动脉损伤或细菌感染。我们什么都做

为了保持肢体的存活，我们治疗并切断了不可存活的组织，但是那个 这并不能保证它会一直这样下去。

在今天的天气条件下，尤其是在战斗正在进行的时候

在沼泽地形上，低体温被增加到战斗伤害。最近 一个在田里待了三天的病人被带到我们这里来了 没有水和食物，肩膀和小腿都有枪伤，

低温和可怕的疼痛。他被推开了

但他无法重新加入他的部队。我们对他做了手术，而他 奇迹般地幸存了下来，这样的病例非常罕见。

![](/media/202412//1733470893.604561.png)

![](/media/202412//1733470893.6131642.png)“It's not the sight of blood that scares you but the possibility of making a mistake.” Confessions of frontline medics

[***Читать на русском языке***](https://theins.ru/confession/257736)

“You get used to soldiers'wounds, but the sight of wounded children throws you off.” OleksiyYudkevich, Ukrainian combat medic

I am a combat medic. When the ATO started,I joined the army and took a tactical medicine course there. During the full-scale invasion I was

involved in evacuating civilians together with a group of volunteers. It all started when a former colleague of mine needed to evacuate his

family from Chernihiv. We figured out a relatively safe route and

managed to evacuate them. Word spread quickly, and people started

calling me on the phone asking for help. Later we received a request to evacuate a maternity hospital where infants had been abandoned – they needed special care, and there was no way to provide it, the city was

under massive shelling. We were given a critical care vehicle, and after a successful evacuation we were offered to keep the vehicle. Requests for help did not stop and considering that our group included quite a few people connected with military medicine, we decided to get serious

about rescuing the wounded on the frontlines.

![](/media/202412//1733470893.623358.jpeg)

**Alexei, combat medic**

We have several teams of doctors and paramedics, most of whom are

willing to travel with me in their spare time. There is a team from the Zaporizhzhia Fifth Hospital, they swap shifts to free up 10 to 14 day

stretches. In addition to doctors, there are volunteers on the teams. For example, we now have paramedics from Sweden working with us. There were times when we went to hotspots as part of special units. For the past four months we have been helping at the stabilization station in Bakhmut.

*Doctors from hospitals swap shifts to free up 10-14 day stretches to travel to the frontline*

We have a specialized platform at our disposal: an ambulance equipped as an operating room on wheels, and a critical care vehicle, which

allows us to perform so-called tactical evacuation. Depending on the location, the evacuation chains may differ. Sometimes we pick up a

wounded person, give him first aid and take him to a stabilization

station where the medics work on him. Sometimes we ourselves act as medics at a stabilization station.

If a wounded person has a thoracic injury rather than a simple shrapnel wound and needs special care, such as drainage or blood transfusion, we take him beyond Bakhmut - to Kramatorsk or Druzhkivka, performing all the required manipulations on the way. For example, when blood

sampling is required on the road, we signal the driver to driveslower.

After all, this is not an ordinary IV with plastic tubes, but a procedure

that utilizes an iron needle, and if you jerk it around the needle can

damage bloodvessels, but if the tactical situation allows it and there is no shelling, Itend to provide the maximum amount of assistance on the

spot, because the chances of the patient being saved decrease exponentially over time.

Every trip is special, and everytime something new happens. Two

months ago in Bakhmut we were the only ones who could provide full medical care, because the local 93rd brigade only had gurneys in their ambulances, and a single ultrasound machine for the entire hospital, including two operating rooms.

*he local ambulance team had only gurneys in the car, and a single ultrasound machine for the entire hospital*

We have a team of doctors who work according to the Damage Control Surgery protocol, a field surgery tactics that had learned in the United States. This format is also called SOST - Special Operations Surgical

Teams. When we travel with such a team,I assist in surgeries - my

qualifications do not allow me to perform surgical intervention: I can perform tracheal intubation or blood transfusion, but I cannot perform a thoracotomy, for example.

![](/media/202412//1733470893.6380293.jpeg)

In 9 out of 10 cases we deal with the consequences of mine blast

trauma. Patients fall into three categories. The first are those who are going to die anyway, because they have injuries that are incompatible with life. More often than not, you start treating such wounded people and already in the process you realize that the patient cannot be saved. For example, you see a massive bleeding from a limb, and then you take off the helmet and see another shrapnel wound under it, and there's

nothing you can do about it. The second ones are the ones who survive anyway, even if we don't pick them up. Survivor statistics are mostly based on them, although they would have survived even without us.

The third ones are those whose lives depend solely on the actions of medics, and this group is the most difficult, the statistics are very bad, and unfortunately there’s no good way of working with them now.

One of the frequent causes of death is external bleeding, that is,

bleeding from the extremities, which is very easy to stop. It's the eighth year of the war, and in most cases we have people who don't knowhow to use a tourniquet <a device for temporarily stopping bleeding - The Insider>. It's pretty common to deal with a minor wound where a

tourniquet wasn’t needed, but was installed, tightened and left for six hours anyway. And as a result, a soldier who might have returned to duty in three weeks ends up with an amputated limb. Or viceversa, a tourniquet wasn't installed, and we had a corpse that had already bled out. If the person who provides first aid turns out not to be competent enough, it may end either in death or in tragedy.

*Oftentimes limbs need to be amputated because many do not know how to stop the bleeding correctly*

Another cause, which in 90% of cases leads to a fatal outcome, is

massive internal bleeding. It can be prevented by following the Damage Control Surgery protocol, which few people here know. It seems to be a simple procedure: open and put a clamp on, in most cases tape over and rush to a hospital, but we keep taking him from one stabilization

station to another until he suffers hemorrhagic shock. In most cases, the chief medical officer, to whom a wounded person is delivered,

thinks that crystalloids (inexpensive saline solutions, for example,

physiological solution) are a good thing and in case of massive blood loss it is necessary to inject the person with Ringer solution, while dry plasma is black magic. But in fact, dry plasma can be very effective in the field. In the event of massive blood loss, it can replenish a large

volume of blood. We had some dry plasma stored in our critical care vehicles, but two months ago one of them was hit by a rocket, and the other one blew up when its oxygen tank detonated.

One day we received a wounded man who, according to all the

documents, was lightly wounded. He had a non-penetrating abdominal wound - a piece of shrapnel had chopped off a piece of skin, and his

condition was classified as acoustic barotrauma - damage to the inner ear. But as we were loading him into the vehicle and strapping him

down, we found he was in hemorrhagic shock due to a hip fracture. A hip fracture is very insidious – it's difficult to detect on initial

examination, and it's fraught with massive internal blood loss: up to

two liters of blood can get inside the muscle, which was what had

caused hemorrhagic shock. After noticing this, we began reevaluating the patient, we identified the fracture, performed bone traction, and

only because we had dry plasma with us, we managed to keep him alive until we reached the hospital, and he survived. If the crew of the 93rd brigade, which was on duty that day, had arrived instead of us, it would have been a guaranteed fatal outcome.

Our work is mostly difficult and unpredictable, and you get used to it, but there is always something you can't get used to. On our last trip, the city fell under heavy fire, and the Russian military hit an apartment

building. Our guys pulled a three-year-old girl out of the building; she had injuries that were incompatible with life. She died on our table. And while you get used to military injuries quickly, injuries to children

throw you off. Children are the hardest part of this story, because for unknown reasons they still stay in the cities, and when you see shell- shocked children playing in the street, it's so... well, it's kind of hard.

*We pulled a three-year-old girl out of the building; she had injuries that were incompatible with life, and she died on our table*

Just like my first combat experience in 2014, when I first saw a wounded man and went into a stupor. As it turned out, this is a fairly common

reaction. It wasn't until my partner slapped me in the face that I got going. But it becomes harder later, when you find yourself in a calmer situation and able to reflect on everything. Then it becomes

frightening: you realize that there were a thousand possible ways for the situation to develop, and it could have been much worse.

“Medics do crazy things, drugs are in short supply, which leads to huge

preventable losses.” N., a Russian intensivist

I have not been to the frontline myself, and Russian doctors who work at the frontlines are strictly forbidden to speak with journalists, so they are unlikely to talk to you. But I talked to military medics who regularly go to the frontlines, and they spoke in detail about their work and

showed me pictures. They are very critical of the medical equipment for doctors and paramedics - everything is obsolete, everything is in short supply, and there’s practically no training being provided to the people who work there, so preventable losses are very high: about 30% of those who die from wounds on the Russian side die from non-fatal wounds

(for comparison, on the Ukrainian side this figure is 5%). That is,

sometimes it is enough to apply a normal tourniquet to prevent a

person from dying, but either there are no normal tourniquets, or there are no tourniquets at all in the kit, or there are not enough first aid kits, or everything is there, but the medics are untrained – and in the end

there’s a huge number of preventable casualties.

The main thing that is missing from the kit is good blood-stopping

material. There are special substances that are placed in wounds,

hemostatic agents that stop the bleeding, good tourniquets and

pressure dressings, but they are either Russian-made or Chinese, and work very poorly, while the Ukrainians have high-quality stuff, so

Russian military medics are very happy when they get a chance to take first-aid kits from wounded or killed Ukrainian soldiers and grab

everything they were supplied with. The best stuff our medics have is the stuff they managed to steal from the Ukrainians.

The Ukrainians have well organized paramedics who come and pick up the wounded, apply tourniquets, stop the bleeding and take them to a place where they can get help. It's true that they have stopped putting doctors in the evacuation vehicles, only trained non-medical personnel -because their evacuation vehicles are targets for our armed forces.

They are very fond of finishing them off because usually there is a large number of soldiers in every such vehicle. It is a war crime to kill

wounded evacuees, and of course no one would ever say it on the

record. But a doctor I know proudly told me those vehicles were being “quickly punished and destroyed.” They don't even hide it, they are

proud of it – if they see an evacuation vehicle with Ukrainian wounded, they try to destroy them.

*The Russian military servicemen proudly tell how they shoot at Ukrainian medivac vehicles, although it’s a war crime*

Military doctors have several levels: medical unit, medical platoon,

hospital. First, they do some critical stuff on the battlefield under fire, then, when possible, they take the wounded to a more or less safe place they can be helped, then they take them to the medical unit, where only doctors work, and then, when a large number of wounded is

accumulated, they evacuate them to the nearest hospital, for example, in Rostov or Belgorod. Those with heavier wounds are taken to Moscow and St. Petersburg. A lot of doctors have been mobilized. Mobilized

doctors try their best to get hospital assignments. Most of them don’t want to work on the battlefield.

In general, the level of training of doctors on the ground is quite poor, but the authorities cannot send good, experienced military doctors

because they have huge workloads at their places of work, so the most qualified ones stay in Moscow and St. Petersburg. The authorities keep sending poorly trained doctors, who can’t do a thing, hence the massive loss of life and limb, which could have been prevented if medical care

was organized properly. An acquaintance of mine showed a video of

Ukrainian doctors at work: they are so professional that it’s clear they had been getting instructions from the United States or Israel, they had been trained to follow their protocols. They have protocols they’ve been trained to follow automatically: measures to betaken to prevent a

heavily wounded soldier from dying quickly, to stop the bleeding and

avoid life-threatening situations that can cause a soldier to die within next few minutes or hours, then deliver the wounded soldier in that

condition to a hospital with highly qualified medical staff. All it takes is simply the execution of an algorithm and the availability of good

![](/media/202412//1733470893.6633277.png)consumables. You can see that the Ukrainian side has everything and that they had been trained because I doubt they knew how to do it in the first place. Very good training.

*Russian medics are unprepared and do some crazy things, while Ukrainian medics act according to Western protocols, they had obviously been trained well*

The medics I talked to were armed. They don't fight, they carry firearms just in case. They can use their firearms until there’s a need to tend to a wounded soldier. A peacetime acquaintance of mine is a pediatric

intensive care physician who worked in a regular children's hospital in Moscow. Some patriotic feelings kicked in, he decided to go and play

war, he actually went as a volunteer. It’s not even a question of money, he just likes it very much. He is about 45 years old, he is brainwashed, he tells you how “khokhly” and “pindosy” <derogatory terms for

Ukrainians and Americans> should be killed and then he shows you

videos of how well everything is organized on the Ukrainian side, and

how bad everything is on our side. And if you ask him why we should

bring the Russian world to Ukraine and not viceversa, he has a ready

answer at once: “They are doing well, because they have been preparing for the war for eight years, unlike us. We didn't know we would be going to war.” He is quite professional in medical terms, but absolutely

brainwashed on the topic of war. On the whole, those with whomI

spoke were pessimistic, but not in the sense that we will lose, but in the sense that the war will be very long. How they psychologically cope

with what is going on, Ido not know exactly, but my acquaintance looks as if he’s a regular drinker.”

“After being surrounded, we had to acquire shooting skills.” Kateryna Galushka, a Ukrainian paramedic

I'm an Oriental historian, but back in 2019 I decided I wanted to do something for the victory and found myself in paramedicine. I took a course in the “Hospitallers” volunteer medical battalion and became part of it. After that,I started my trips to Donbass as a military

paramedic.

We serve in rotations on the first line, we call it “ground zero.” It is

equidistant from all trench positions on the battlefield. You are on duty is 24-7 when on a rotation. If you're asleep, you wake up, go and pick

the wounded up. The rotation itself can last anywhere from two weeks to infinity, depending on how long you're willing to work. Unlike those who serve under contract, we make our own schedule.

![](/media/202412//1733470893.6770418.jpeg)

**Katerina, a paramedic**

According to the [MARCH](https://www.crisis-medicine.com/category/march/) and [TC3](https://en.wikipedia.org/wiki/Tactical_Combat_Casualty_Care) protocols, we should not provide first aid while on the battlefield because it endangers the lives of both

paramedics and the wounded. Accordingly, the maximum that can be done in the trenches is to put tourniquets on a person's limbs and

quickly load them into a vehicle. And while the vehicle is on the move to the second stage of the evacuation, we provide all the necessary aid: stop massive bleeding, ensure normal breathing, air circulation, deal with any complex injuries that require surgical intervention, stabilize the wounded person, that is, administer antibiotics, painkillers, and

infusions.

We usually try to do everything very quickly, before shelling starts. We can work under heavy shelling, but we need to stay away from the fire, especially from small-caliber guns such as machine guns and assault

rifles. It’s always for the paramedic team commander to decide whether to pick up a wounded soldier under heavy fire. There were times we

wouldn’t be allowed to go or I myself would decide not to go,

understanding I could not put the lives of other team members at risk. I can risk my own life, but not the lives of others.

![](/media/202412//1733470893.6867404.jpeg)

The war showed that even medics need to knowhow to handle

weapons. Initially our battalion commanders were not happy with this, but after Mariupol, where medics had been encircled, many of us

learned basic shooting skills -because you never know what might

happen and where these skills might be needed. I’ve also taken special courses and try to practice at a shooting range once a month.

When you see someone wounded, it's not the sight of blood or injuries that scares you,it's the thought that you might not be able to cope.

Even after three years,I still have fears I might not do enough, but

fortunately, no one has died in my hands. While treating my first

wounded soldier, I was very afraid I might fail to tighten the tourniquet or bandage the wound the right way. The most important thing in such situations is to remember that a person's life is in your hands, and it

![](/media/202412//1733470893.6984096.png)depends on you whether they will be able to return home. I always try to stay calm and stick to protocol, convincing myself I’m doing the best I can.

*When you see a wounded person, it's not the sight of blood or*

*injuries that scares you, it's the thought that you might not be able to cope*

Before March 5 I simply did my job as I was supposed to, and it had no effect on my psychological state, but afterwards, when the man I loved died, it became very hard for me seeing a man wounded, let alone killed. On top of that, I’ve been constantly experiencing a lot of shocks that I don't have time to reflect on.

When I see a dead person, I always think that the man I loved was

probably lying like that too, or that someone close to me, who is also at war now, might be wounded as well. Sometimes it's psychologically

hard to bear it. As for the wounded, it's hard for me to work with them, too: I worry about them,I want them to survive, because I know what it's like to lose someone, and so I get nervous a lot. But I always try to remember why I got into this in the first place.

*When I see a dead person,I always think that the man I loved was probably lying like that too, and I try to save everyone I can*

Since the start of the full-scale invasion,I have been working in an area of defensive, rather than offensive actions, which is why shrapnel

wounds from mortars and artillery are what I have to deal within most cases. I did not encounter many bullet wounds, only four, but they were the most difficult to treat. Lately there have been a lot of wounded,

especially those who stepped on anti-personnel “petal” mines. They are dangerous because they are invisible and blend well into the

environment. “Petal” mines are often scattered across the grass or

within urban environment, and when a soldier steps on such a mine, it either rips off his foot or severely injures him.

![](/media/202412//1733470893.7090797.jpeg)

**Anti-personnel blast mine (PFM-1) also known as “Petal”**

Paradoxically, I feel safer at work than Ido at home. When I’m on a

rotation there is always a man on duty to warn me if there’s any danger, and when I am on leave I may not hear the sound of an air raid and no one will be standing next to me with an assault rifle.

“The guys don't understand why they didn't die, and more importantly, why they were there at all.” K., a Russian military surgeon

I have worked as a military doctor all my life, and what's happening now doesn't shock or scare me in anyway - it's not the first time in my life

that I've seen wounded people. It's my job, just like any other doctor's, just a little bit different. The only difference is that in peacetime there are fewer wounded and now there are more, but I cannot name specific figures, nor can Ispeak about my work with servicemen brought in from Ukraine - I signed the relevant documents.

I try not to think about the war, because if I start naming the recent

events in this way, Iwill have to make an assessment of it, take a stance, but I can't take a stance. My duty as a surgeon is first of all to save

people, to save as many as I can, not to ponder on who’s right, who’s

wrong and who’s to blame for what’s happening. Besides, you know very

well what position I’m required to adhere to. This is not about medicine.

When you encounter the first wounded in your life, you are scared, but not of blood (I would hardly have gone to medical school had I been

scared of blood); you are scared of not being able to make the right

decision, you don't want someone to die because of your fault.

Psychologically it is hard, but we’ve been taught, or ourselves learned, to cope with it.

What we are dealing with now are textbook cases of everything that can be found in military surgery: all kinds of soft tissue injuries, fractures, amputations, shrapnel wounds of different character and degree. It all depends on who was brought to us, whether the person blew up on a

mine or came under fire.

![](/media/202412//1733470893.7207835.jpeg)

A lot of mistakes have been made by those specialists who worked

before us and apparently were dispatched to the front without proper training - after being treated by them patients often lose their limbs,

and that's not the worst thing that can happen. I see these mess-ups

very often, and I realize that if the wounded person had been treated by a more competent specialist, he would have probably kept his limb. I

know who is being sent to the front now, there’s a large medical

community, and doctors share information with each other. When you hear that a specialist is being sent to the front who has just graduated from university or hasn’t even graduated yet, you understand what will happen to his future patients. Often even we are not able to rescue a

patient, despite the fact that we are not on the frontline and can

provide the appropriate care. By and large our hospital, in spite of the level of the specialists'training, turned out not to be ready for the

influx of wounded and for working in such conditions - quite often there is simply no necessary equipment to conduct research.

*Our hospital was not ready for the influx of wounded*

A lot of wounded are being brought in, and often they are young guys who have not yet had time to live, but are already disabled, unprepared for, and internally broken by, what has happened. I've seen a lot of

those empty eyes lately - guys don't understand why they're alive, why they didn't die, and most importantly, why they were there at all.

“Sometimes we work without lights, the generator is only for the operating room and ICU.” P., a Ukrainian

military surgeon

Before the war, I was serving at a mobile hospital in the Joint Forces Operation area in Donbass for two years and I could not leave the

compound for more than fifteen minutes, because at any moment a wounded person could be brought in. The conditions were almost the same as now, the only difference being that there were a thousand

times fewer wounded.

It’s always scary to look at them, although the concept of fear is

incompatible with medicine. We worry a lot about patients, especially when there are unusual cases and it's hard to decide what to do right away. But, fortunately, we don't work alone: there's a whole team of specialists in the hospital, some of whom have 20-25 years of

experience in military medicine or surgery. Personally, I treat wounds using external fixation devices and amputations, but I can also help surgeons of other specialties if need be. It is important to understand that we provide comprehensive specialized care, but not highly

specialized, because the wounded are subsequently taken to big cities for further comprehensive treatment.

70% of the wounds are soft tissue related, and this number is similar to the WorldWar II statistics; some of them are gunshot fractures of

bones, small or large. The character of the wounds largely depends on whether it was artillery fire, rocket attack, air raid, landmine or small arms fire that caused them. What matters is the kind of explosive that was used in the mines.

A wounded person may have a huge piece of shrapnel embedded in his body that does not affect vital organs, or he may suffer from small

wounds, with some of the vital organs injured. For example, a patient

has no major injuries, only a small shrapnel wound in the shoulder with damage to the brachial artery. Such an injury, if not treated in a timely manner, can result in either amputation of the arm or severe blood loss,

causing shock and death. There are only ten minutes to apply a tourniquet.

*There are only ten minutes to apply a tourniquet in case of a brachial artery injury*

Before a patient goes to the hospital, other medics work on him. It's a lot harder. If we have a calmer situation, the pre-hospital doctors have to get the wounded man out of the battlefield and quickly administer first aid. It sometimes happens that a wounded serviceman cannot be extracted for several days due to prolonged shelling, when everyone is under enemy fire, and medics need to make sure that he makes it to us and doesn't die. That's why our fatality rate is minimal: it all depends on timely action on the frontlines.

A few days ago, we had to work during a blackout, with a huge number of patients coming in. For such cases, our hospital has a generator,

which serves the operation room and intensive care unit. But only 10- 15% of the wounded need surgery, the rest are sent to the wound

dressing rooms or the antishock rooms. When there is virtually no

lighting, it is difficult to work in those rooms. There are also big

problems at the triage stage: it is necessary to separate the heavily

wounded from the lightly wounded, without missing any wounds that are not clearly visible -the size of an entry wound can be as small as one millimeter.

*It's hard to work when there's no light. Sometimes you have to look for millimeter-sized entrance wounds*

There are a lot of wounded, but some of them you get to remember for a longtime - not because of the severity of their wounds, but because of their specific stories. I had one patient from Mykolaiv. When he served in the Luhansk region, his daughter was killed. Another one was from

Lviv, he worked as a gardener before the war and went to the front without any experience. He had such kind eyes. War snatches people away from peaceful life and forces them to take up arms.

I hear a lot of stories from lightly wounded patients as I dress their

wounds or talk to them before surgery. They tell me what the situation on the frontline is like, where they are from. Most of the wounded I

remember well are amputees. Those are mostly traumatic amputations, when a piece of shrapnel cuts off a foot, an arm, a hand, a forearm or a hip. It’s hard to forget such patients because they are young guys who should have been enjoying their lives, working hard and playing sports. But tragedy comes into their lives when they lose a limb.

Depending on the unit they served in and their age, they cope with it in different ways. Professional servicemen understand that they are alive and that they will be able to play sports and even serve with a

prosthetic limb, while recruits and civilians don't believe they can cope; it's very difficult psychologically for those patients. I recently had a

wounded man, with a foot attached to the leg by the skin and two

tendons. Before the surgery, the foot was cut off because it was easier to move the patient that way. It was already almost a complete traumatic amputation without reconstruction of the arteries and the bone, which occurred due to a massive tissue injury that will never heal.

About 70% of our patients are already miss a limb and understand they will be left without one. At the same time, they feel no pain, because

they are under heavy sedation and maybe in a state of shock, but not because of the injured limb, but because of massive blood loss. Our goal with such injuries is to preserve the tissue as much as possible so that we can strengthen it in the future forgetting a good residual limb to fit into the socket of a prosthesis. There are cases when, even after our

help, a limb still has to be amputated because of huge bone or soft

tissue defects, artery damage, or a bacterial infection. We do everything to keep the limbalive - we treat and cut off non-viable tissues, but that is no guarantee it will stay that way.

In today's weather conditions, especially when the fighting is going on on a swampy terrain, hypothermia is added to combat injuries. Recently a patient was brought to us who had been in the field for three days

without water or food, with gunshot wounds to his shoulder and shin, hypothermia and terrible pain. He had been pushed away from his

position and was unable to rejoin his unit. We operated on him, and he miraculously survived, such cases are very rare.