Makeshift Medical Care Amid Mayhem of War

Peter Kowalski, MD;

On February 24, 2022, after the monthslong buildup of Russian troops on the Ukrainian border, the Russian invasion began at 5 AM. They formed a pincer movement on 3 fronts, seeking to secure predominantly Russian ethnic regions in the east of Ukraine, to establish a land bridge from these eastern regions on through the south to Odesa. This would allow them to control the country’s Black Sea seaports and energy sectors, and to push troops south from Belarus to Kyiv to decapitate the government. The abandoned Chernobyl nuclear reactor was invaded and 19 sailors on Snake Island told the Russians to “go f---” themselves rather than surrender. The world embraced the Ukrainian cause, and I felt the need to be there.

I had some experience working in disaster areas. In February 2010, I was pitched in the middle of a sea of refugees in Haiti after the major earthquake of January 12. I remembered being petrified the night before seeing patients, fearing I had absolutely nothing to offer them. When I went into my makeshift office the next day and saw my first patient, all that terror melted away as my training and experience took over. I found that a psychiatrist can do a lot in a disaster. Over the years, I continued traveling there, establishing a small mental health clinic with the help of a nurse, video conferencing, and concerned colleagues in the United States. I felt I could lend a hand in Ukraine.

Going there was not my idea alone. An advanced nurse practitioner I work with, Brandie, was thinking the same thing. Discovering we were thinking alike, Brandie and I began to plan how we would get there. As the days passed, we learned more about the refugees’ plight and our need to help grew. Groups that were forming to assist were embryonic and disorganized—typical under these circumstances. We finally connected with a group that was sending volunteers to Cieszanów, a town in eastern Poland 16 miles away from the Ukrainian border at Budomierz and 72 miles from Lviv, the cultural capital of western Ukraine. We decided on March 10 that we were going, leaving us 72 hours to book flights and collect donated medications and supplies in 7 trunks to take with us.

By this time, NATO had put troops on standby, Ukrainian President Volodymyr Zelenskyy refused to leave Kyiv, Elon Musk had turned on his Starlink satellite system over Ukraine so the Ukrainians could talk to each other, and 2 million individuals had already left the country for Poland, Hungary, Moldova, Slovakia, and Romania. Putin demanded the demilitarization and “denazification” of Ukraine along with its military neutrality. A nuclear power plant was shelled by Russia. A line of 700 individuals waited 13 to 30 hours in 23 °F at the Budomierz crossing—and 5 froze to death there.

"The refugees looked like they were going to the airport to leave on some kind of trip, but their faces spoke of weariness and loss."

Getting there was relatively easy. Brandie and I left March 14 and arrived there the evening of March 15. Many people thanked us for our help and our supplies. That night, we drove 3 hours east from Krakow in a small SUV that barely held all the trunks we brought. We found our lodging, a small B&B that had housed refugees at first and now was housing volunteers like us. We met the American contingent and British health care workers who threw in with us. A folk music festival organization called Folkowisko that holds yearly festivals there had been rapidly transformed into a relief organization thanks to the leadership of Marcin and Marina Piotrowski. By the time we arrived, Russia had just bombed a military facility west of Lviv, near our border crossing. An old journalist friend of mine who had been in many war zones advised me to strap our passports and other vital documents on our bodies, to write contact telephone numbers on our arms and chests, and to keep a spare set of eyeglasses.

The nights were lively at Folkowisko. Vodka, beer, and stories flowed freely. One local politician, his tongue loosened by drink, demanded, “Why are you really here?”

My intention was to provide whatever psychiatric care I could, through counseling and medications, to reduce the impact of trauma on the refugees and their helpers. I wanted to deliver both psychiatric and nonpsychiatric supplies and medications that were greatly needed in Ukraine and to lend support to their efforts. If you bring much-needed skills, being there gives hope to others. But without those skills, you are only getting in the way.

A home improvement center in Cieszanów was rapidly converted into an all-purpose warehouse and docking station for the many trucks and buses headed into Ukraine, as well as a dining hall and bunkhouse for the many volunteers. It ran night and day. I have never seen such a singular effort accomplished by so many people. Around the clock, volunteers drove forklifts with pallets full of supplies, and people loaded vehicles meant for other purposes, like tour buses. A Welsh cook filled stockpots with delicious stew. My bottle of habanero Tabasco sauce found its way into his condiment supply and it made a delightful chili. People had come from all over Europe, the United Kingdom, and Ireland.

A large room was used for medical supplies and equipment, and Brandie and I, being the only medical people there, sorted out the array of pharmaceuticals from many countries. As they were labeled in many languages, we relied on the generic names to group them. We came to realize that no direct medical care was being provided at Cieszanów. The closest thing to this was a medic outpost inside the Ukraine border at Budomierz. Our first full day there was stocking medications and waiting for a chance to go to the station.

The next day, we and 2 British volunteers set out to be useful. Francis from Ipswich, a newly minted nurse, and Kasia, a grad student in computational enzymology who spoke Polish, went to Budomierz. We were turned back at the border because rental cars were not allowed to cross, and we could not carry our supplies by foot. The border guards seemed to want to help us, but they were constrained to follow the rules. We drove to Medyka, 45 miles south, and again tried to cross. Kasia managed to find an American volunteer named Angel to help us pass, but we were refused because we were not part of an organization that had been established there, and because if we went into Ukraine, we would be expected to stay there, which we were not prepared to do.

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At both border crossings, we saw refugee groups made up of almost all women and young children, pulling roller boards with all their possessions behind them. Few men were there, as they were not permitted to leave the country but were conscripted to fight instead. The refugees looked like they were going to the airport to leave on some kind of trip, but their faces spoke of weariness and loss.

We were asked to serve a shift at the medic station early that morning. We had been warned to dress warmly, as the temperature was subzero and the winds were blowing fiercely. Joining us were 3 individuals who lived in Bulgaria: a newly graduated medical student from Mexico named Ana and 2 journalism students, Anastasia from Ukraine and Ethan from the United States. We were fairly warm within the station, a specially outfitted medical trailer donated from Poland, but outside, the Ukrainian soldiers huddled by a big bonfire from the trees they cut down nearby.

There were no cots in the trailer, so we slept upright on white plastic chairs. The flows of refugees had slowed by that time, and it seemed that most of them were crossing through Medyka.
We did help a few, changing bandages on recent shrapnel wounds, but most of our patients were the soldiers themselves. They were both men and women, and they looked young and maybe freshly conscripted. Their faces appeared wind-burned and they requested items like eyedrops, lip balm, nose spray, and even fish oils.

Next to the medic station was a tent reserved for nursing mothers and another tent with toys for the children. Across the road was a long line of tents for refugees to sleep in and a small mess that served tea and pastries. The countryside was made even bleaker by the presence of a cemetery next to the camp. We woke to the sound of an air raid siren at 5 AM as the Russians bombed an ammo dump this side of Lviv. A plume of smoke covered the rising sun in the direction of Lviv. We had heard that Russian saboteurs were prowling this part of the country, setting tar fires on farm fields to render them infertile.

Brandie was called upon several times over the following days because of her critical care experience. The medical coordinator assigned me the task of counseling and mediating tensions that had developed among several volunteers. The theories of Wilfred Bion on group dynamics proved useful. I used concepts like fight-or-flight, dependency, and pairing to help the volunteers to reframe their differences and understand their conflicts as an outcome of groups under severe stress. They then resumed their energies in the interest of the work group rather than the basic assumption group.

The medical coordinator also gave me the task of writing a guide for the volunteers because none of them were trained in mental trauma. I wrote “Psychological First Aid for Refugees and Providers,” had it translated into Polish, and distributed it to our group and others. It will be published in the April-May edition of the Journal of the Oklahoma State Medical Association. In it, I describe what traumatization is, what the aftermath is when it happens, what the approach for nontrained volunteers should be to traumatized persons, some suggestions for medication management, how to limit secondary trauma to the volunteer, and the effects of trauma on overall group functioning. I wrote it in the same afternoon the Russians bombed 400 civilians sheltering in a theater in Mariupol.

Both Brandie and I were exhausted and I could tell she was getting homesick, as she expressed a desire to eat at her favorite Mexican restaurant the moment she returned. We decided to leave a day early to decompress in Krakow, and our trip home was uneventful except for jet lag.

When we returned, the Ukrainian forces had begun to push the Russians away from Kyiv. A lot has happened there since, and at the time of this writing, horrible war crimes are being discovered in a suburb outside of Kyiv. Civilians were bound and shot, left in the streets for dogs to eat. Piles of charred bodies, some of them children, were discovered near an empty playground. Unimaginable torture was apparent on their corpses.

I have not left Ukraine in my thoughts. Although I did not see these horrors or talk with the refugees, being in that place and talking with the providers has left a deep cleft in my cortex. I stay in touch with other volunteers and try to help as much as I can. I honor their courage and resolve.

This must stop. This should not be happening in the 21st century. I hope and pray for the refugees, their helpers, and all who have been injured. May peace and security be reestablished soon.

Dr Kowalski is the chief medical officer of NorthCare of Oklahoma (North Oklahoma County Behavioral Health Center) in Oklahoma City, Oklahoma. He is an adult, child, and adolescent psychiatrist and has been in practice for 32 years. He is also a clinical assistant professor in the department of psychiatry at the University of Oklahoma College of Medicine. ❒