Photo: Rehabilitation of veterans in Ukraine (facebook.com/Superhumans.Center) Author: Katerina Goncharova
How the military should be returned to civilian life and why it is difficult to find good rehabilitation specialists in Ukraine – in the material of RBC-Ukraine journalist Katerina Goncharova.
In less than two years of the great war, thousands and thousands of military personnel were seriously injured at the front. There are more and more victims who require long-term rehabilitation literally every day.
In Ukraine, they are working to create a rehabilitation system in which a veteran would be included immediately after injury and would be accompanied virtually throughout his life.
Veterans say that now it is difficult to get the necessary services, and often they have to be literally “knocked out.”
“Most veterans actually do their rehabilitation themselves.”
“If you are a warrior, then you must be a warrior to the end. Because after returning from the front, there is also something to fight with. Sometimes you yourself need to have a legal or even medical education, because you have to figure out everything: from finding a really good rehabilitologist to issuing certificates and defending rights to payments,” says Ruslan “Punk” Romanov , a volunteer of the Azov Special Forces, to RBC-Ukraine.
The man went to the front at the beginning of 2015. In addition to Azov, at various times he served in the special forces of the National Guard, in the Marine Corps – the 503rd separate battalion was based in Mariupol. In May 2022, in the Zaporozhye direction, he was wounded, the consequences of which will remain with him for the rest of his life.
Ruslan at that time was a platoon commander and had to get the guys into position. I decided to carry out additional reconnaissance: I went together with the driver to look at the location. A mine detonated on the road and exploded right under the car. Ruslan survived, the second military man miraculously remained unharmed.
Photo: Ruslan was wounded in May 2022 in the Zaporozhye direction (provided by the speaker)
“After the explosion, I was stuck in the car and was knocking down the door from the inside. The driver helped me remove it and get out. There were many injuries, the leg suffered the most,” recalls the soldier.
Since May last year, Ruslan has undergone four operations. They installed an Ilizarov apparatus, removed the ankle joint and put three pins in its place. Recovery from the injury continues now, for more than a year.
“Six months after the injury, I gradually began to get back on my feet. For three months my body was practically at zero, I was dizzy, I couldn’t sleep. I also experienced very severe pain for a whole year because the bones were fused. It was very difficult psychologically and physically. Only Now the nervous system is gradually coming to its senses. Although while still lying in bed, I continued to volunteer and help the guys. Now I can only walk a short distance without crutches,” says Ruslan.
At first he really wanted to return to the front, he thought that he would soon recover. But due to injury, he will no longer be able to wear a bulletproof vest. Doctors also said that Ruslan would never be able to run.
For a serious injury at the front while undergoing rehabilitation, the military should be paid 100 thousand hryvnia per month. Ruslan is not receiving them yet: this requires the appropriate conclusion of the VLK and the medical and social expert commission. In addition, there are still many issues that need time to be resolved. And walking through authorities with a crutch is extremely difficult.
“It often happens that military personnel are undertreated and discharged. I was lucky: at first, Azov’s patronage service helped me. But most veterans actually do the rehabilitation themselves. When you find yourself with a whole list of questions, some will go all the way, and others won't stand it and will begin to “melt”. A friend of mine had to have his legs amputated after being wounded. He closed himself off, stopped communicating. And I don't even know where he is or what's wrong with him,” the defense lawyer describes the problem.
Photo: The military man undergoes rehabilitation himself, but at the same time does not forget to help his colleagues (provided by the speaker)
Tens of thousands of people need prosthetics
Before the Russian invasion, 90% of amputations in Ukraine were mainly lower extremity amputations at the level of the foot and lower leg. Most are due to vascular diseases of the legs – diabetes and others. There were also injuries from road accidents and cancer. But due to the aggression of the Russian Federation, thousands of defenders began to need prosthetics and rehabilitation. The need has become enormous.
Rehabilitation has been developing for a long time according to old post-Soviet canons. In recent years, the situation has changed significantly, but still the war and its consequences are a huge challenge, says medical director of Superhumans and former head of the National Health Institution Andrei Vilensky . In the center, which opened in the Lviv region at the expense of foreign investors, they create free prosthetics for military personnel and provide them with comprehensive free rehabilitation after injuries.
“Due to the war in Ukraine, the structure of amputations is completely different. 30% or more are upper limbs, many amputations are above the knee. Sometimes a defender even needs to amputate two arms and two legs. In Ukraine, rehabilitation and prosthetics services have been separated for a long time. Until now rehabilitation is handled by the Ministry of Health, and prosthetics is the responsibility of the Ministry of Social Policy. Although prosthetics is an integral part of rehabilitation, it must be an integral structure,” says the specialist.
Photo: The need for prosthetics due to the war in Ukraine amounts to tens of thousands of people (Katerina Goncharova/RBC-Ukraine)
According to his estimates, there are now only about 10 specialists in Ukraine who can really effectively work with upper limb amputations.
“The actual capacity is to produce no more than 100 prostheses per month, but the request goes for thousands. Data on needs during the war are closed, but one way or another the request is huge. I would estimate it at tens of thousands of people who need prosthetics,” adds Vilensky.
Almost everyone who had the relevant profession has already been included in this process. Those who produce prosthetics, as well as rehabilitation specialists and other specialists.
“At the beginning of the great war, there was no comprehensive training program for prosthetics specialists. We initiated its creation, and today the Lviv Polytechnic will have a state order for such specialists. In this way, we lay the foundation for the future, because the patient will have to undergo rehabilitation for the rest of his life. In addition, the prosthesis itself will need to be changed in two or three years,” notes Andrey Borisovich.
In his opinion, it is better to attract specialists from abroad in Ukraine than to take veterans to other countries for treatment. It is necessary to create these services in Ukraine.
“For this we are looking for partners all over the world. Our mission is to create a model that the state could further spread throughout Ukraine by developing a regulatory framework for it. This needs to be done soon. But we simply don’t have time. The longer it takes to get injured, the less likely the patient will be able to use the prosthesis in the future,” he points out.
When asked how to get treatment and rehabilitation at the Superhumans center, the doctor assures that they do not have a specific selection process. They also provide assistance to civilians.
Simply fill out an application on the center’s website. Next, the manager will contact the patient, and specialists will study the medical documentation regarding the possibility of taking the veteran to them. It is necessary to examine the patient in person: for this he is included in the waiting list. If there are obstacles, for example, a wound needs to heal, doctors give recommendations for rehabilitation.
Photo: In Ukraine there are still few specialists who can effectively work with amputations of limbs (Katerina Gochnarova/RBC-Ukraine)
“In fact, we are strengthening the state’s capabilities in rehabilitation. Currently there are about 700 patients on our waiting list, more than 600 of them with amputations. Since opening in April, more than 200 patients have been given prosthetics or taken for rehabilitation. We plan to open centers in Dnieper, Kharkov, Nikolaev. And when the Ukrainian armed forces liberate Mariupol, we will also open a rehabilitation center for our defenders and civilians there,” the medical director shares his plans.
Open question. How to return a veteran to civilian life
Centers such as Superhumans are excellent initiatives funded by foreign philanthropists, but the rehabilitation system itself will still have to be expanded to the all-Ukrainian level. This should become state policy, says RBC-Ukraine v.i.o. Head of the Accounts Chamber Andrey Maisner . According to him, there is little chance of getting into such a good clinic if the veteran is not “picked up” and is not led by volunteers. And the need for prosthetics is enormous.
This year, the Accounts Chamber conducted two audits of the situation with rehabilitation and prosthetics, starting from the time of the Revolution of Dignity and the ATO to the large-scale war. And they claim that the results are unsatisfactory.
“Unfortunately, the war does not spare our heroes; they lose both life and health. This is a tragedy. Often those returning from the front due to wounds cannot live a full life. The state was not ready for this. We have studied the situation for four years – since 2019 until 2022, in the regions and at the central level and identified many problems,” he says.
The register of citizens in need of rehabilitation in war conditions for security reasons should be closed. But not everyone who needs such help is included in the register. Many drop out of registration and do not receive help, the interlocutor notes. According to the Accounts Chamber, in 2019-2022, more than 83 thousand veterans did not receive free rehabilitation services guaranteed by the state.
“After being wounded, a veteran is included in the general management of the Ministry of Health and receives assistance on the same terms as civilians. But regarding prosthetics, the Ministry of Health directly tells us that this is not for them,” the expert describes the problem.
Secondly, there is still no clear algorithm for how to return a combat participant to civilian life.
“How will a veteran be greeted in the community? Everyone will have post-traumatic syndrome to one degree or another. Who will help overcome it? Where can a defender look for work? When I ask veterans I know, they don’t even know where to go for this. Different departments work on their own. on its own, but it has to be an integrated system. Everyone has to work together towards one common goal,” Meisner notes.
Rehabilitation should be not only physical, but also emotional and psychological, says veteran Ruslan Romanov. In 2021, even before the large-scale invasion of the Russian Federation, he already had psychological problems after his time at the front. I started reading books about how to help myself, because “I had to pull myself out.” He is convinced that it is military psychologists who should help with this, and there are very few of them.
Photo: According to the Accounts Chamber, in 2019-2022, more than 83 thousand veterans did not receive free rehabilitation services (facebook.com/Superhumans.Center)
“I turned to a psychologist, but she said: “Since you are already so smart and help yourself, then why do you come here and take up my time?” As for mental health, not everyone will understand the military. These are problems of a different category, not peaceful problems life. This requires a different approach, and it is difficult to find an appropriate specialist. My wife supports me in everything, I am incredibly grateful to her,” he says.
It is also unknown exactly how many people need psychological help, and there are not enough specialists to provide such services, says the acting head of the Accounts Chamber.
“A military psychologist is a separate specialty. It must be a physician. It is advisable that the person himself has been at the front. An “ordinary” psychologist cannot cope. After all, veterans are people who saw the death of friends and almost died themselves. One defender told me: “He came I’m going to see a psychologist, she’s such a smart girl. But 5-6 minutes into the conversation, she burst into tears. It was no longer she who calmed me down, but I who calmed her down.” There should be a separate state order for military psychologists. If this is not done, we will get huge social problems,” says Andrei Meisner.
“Do everything to prevent a person from becoming a person with a disability.” What will the rehabilitation of veterans be like in Ukraine?
Ukraine indeed inherited the post-Soviet rehabilitation system. In fact, the first significant changes began in 2016, when new specialties were introduced at universities: physical therapists, occupational therapists and others. Subsequently, the law “On Rehabilitation in the Sphere of Health” was adopted. This allowed the industry to develop, as is now being done in the world, the Ministry of Health tells RBC-Ukraine.
“After the start of the Russian aggression, the creation of an adequate rehabilitation system began. It is necessary that rehabilitation begin as early as possible. When a patient, say, after a traumatic brain injury ends up in the hospital, then rehabilitation specialists should begin working with him. Since irreversible damage may begin processes, and time will be wasted. When a person no longer needs hospitalization, but there is a limitation in his functions, he should be sent to the rehabilitation department. We need to do everything to prevent a person from becoming a person with a disability,” comments Vasily Strilka , director of the department of high-tech medical care and innovations of the Ministry of Health of Ukraine.
In the department, a person must receive three hours of rehabilitation per day. For a rehabilitation course for one person within 14 days, the medical institution receives an increased tariff – 19,700 hryvnia. For a 21-day rehabilitation course – 33,600 hryvnia.
Photo: After the war, veterans really need psychological rehabilitation (facebook.com/Superhumans.Center)
“The increase in tariffs stimulated medical institutions to attract more specialized specialists. Their number has almost doubled. Now all such institutions in Ukraine are able to receive more than 8 thousand patients a day. Our need is exactly 7-8 thousand. We are guided by the experience in Israel: there for a population of 10 million there are about a thousand rehabilitation beds. But in Israel, community-based care works very well, we still need to develop this. In Ukraine, international teams of rehabilitation specialists are constantly teaching our colleagues,” he adds.
But, according to Andrei Maisner, rehabilitation should develop from the opposite – not from how many hospitals want to provide such a service, but based on the real needs of veterans. To do this, you first need to know how many defenders really need it.
However, Ukraine has achieved a lot in a short time. For example, the concept of rehabilitation after burns did not exist in Ukraine at all until February 24. And now burn centers in Vinnitsa and Lviv are already attracting physical therapists while burn surgeons treat wounds. Therapists try to develop limbs so that patients do not have severe contractures and scars. Ukrainian specialists were taught this by foreigners, the Ministry of Health says.
A national rehabilitation center for spinal cord injuries is actively developing on the basis of the Rivne Regional Veterans Hospital. Specialists from Norway, Australia and other countries work there. And high-quality prosthetics have already been established at several hospitals in Ukraine.
According to reviews from the military themselves, one of the best government institutions for psychological rehabilitation is the medical rehabilitation center “Pushcha-Voditsa” of the Ministry of Internal Affairs of Ukraine. To get there for free treatment, all you need is a referral and a call from the veteran’s family doctor. The defenders themselves say that they get a lot of help there, and the doctors are all professionals.
The demand for rehabilitation specialists will only grow over time
Now there are always places available in rehabilitation institutions in Ukraine, the Ministry of Health assures.
“The system is not overloaded, but rather the opposite. We see a certain underload. The state provides funds for rehabilitation regardless of whether it is civilian or military. Every citizen of Ukraine has the right to at least two rehabilitation cycles per year. For severe injuries and amputations – up to 8 cycles per year. The state pays for all this,” adds Vasily Strelko.
Rehabilitation departments are located in multidisciplinary hospitals in large cities. The idea is to have at least 30 beds for such patients.
For very complex injuries, such as spinal cord ruptures, five specialized centers will operate for patients in Ukraine in the future. It is also planned that an outpatient veteran should receive care closer to home, so as not to travel 300 kilometers or more.
Photo: Now hospitals receive funds for rehabilitation at an increased rate. Rehabilitation departments are located in multidisciplinary hospitals in large cities (Ekaterina Goncharova/RBC-Ukraine)
“We already have over 400 medical institutions that have entered into agreements with the NHSU on the provision of rehabilitation services on an outpatient basis. 262 medical institutions are contracted by the NHSU for an inpatient rehabilitation package. We will need specialists, so this year we have a government order for 10 years. I am convinced that in the future, the demand for such professionals will only grow; in fact, changes in this direction have only just begun, and significant shifts are ahead,” adds Vasily Strilka.
In the meantime, there are big questions about the qualifications of some rehabilitation specialists, says veteran Ruslan.
“Not everyone understands that injuries received in war have their own specifics. Last year, in the first two weeks, I changed three rehabilitation therapists only because they tried to bend my leg in a way that it should not have been done. They also gave me too much stress. At first I thought that it was necessary, because it was painful, but it turned out that this was wrong and could only worsen the condition,” says the military man.
Because of the war, many Ukrainians faced unprecedented difficulties in different aspects at the same time, Andrey Maisner is convinced. After injury, you need to recover physically and psychologically. If you don't start helping the veteran on time, the problems will get worse over time.
“This is a huge set of questions. We still have to answer the question of why veterans should achieve what they need, why they do not receive services or receive them with a delay. And these problems need to be solved as quickly as possible,” he says.