Ukrainian drugs at the front: What can be found in the military IFAKs and medic packs?

Since the beginning of the full-scale invasion, the number of the Armed Forces of Ukraine has almost tripled – up to 700 thousand men, and the entire security and defence sector (including border guards, the police and the National Guard) now makes about 1 million people. Naturally, the needs for supplying the defenders, including medical supplies, have grown just as rapidly, and due to the sharp increase in demand, there have been some problems with centralised supply, in particular, of combat first aid kits. To help the army, volunteers, charities and NGOs have started to equip individual first aid kits for soldiers and bags for combat medics.

Mind took a closer look at a few such first aid kits and one medical bag, found out how many Ukrainian medicines and medical products are used at the front, and also examined what a modern military first aid kit must actually be like.

What are the standards for the soldier's medical kits in Ukraine?

The Order of the Ministry of Healthcare (MoH) of Ukraine No. 6 of January 5, 2017 regulates the main requirements for tactical medical kits. The act approved, among other things, the "List of Medicines and Medical Products to be in Standard-Issue Individual Medical Kits (SIIMK)." The mentioned format of the medical kit matches the standard of the American Committee on Tactical Combat Casualty Care, which is followed by NATO militaries.

"Take the American IFAK (Individual First Aid Kit) and our SIIMK – their contents are actually the same. That is just 90% was "copied and pasted." And this is fine. Because the TCCC Committee standard is based on the statistics of previous wars, and there is something to rely on," Ivan Nikolenko, head of tactical medicine at Solomyanski Kotyky ('Solomyanka Kitties') charitable foundation, explains.

The IFAK is equipped in such a way that a fighter can provide himself with first aid or immediately receive it in case of injury and before the evacuation. This is done with the means from his IFAK, which mainly includes medical items and consumables.

This list from the MoH allows supplementing kits with additional medicines and medical products, depending on the task, the serviceman's training level and the likelihood of potential damage by radiological, chemical or biological weapons. The American IFAK in its extended version, in turn, is equipped with: an eye shield (pad), an additional bandage for tamponade, a decompression needle and a hydrogel burn relief pack.

What is wrong with the Ministry of Health standard?

Combat medics, medical officers and tactical medicine instructors point out that the standardised model of a first aid kit that is approved by the Ministry of Health is not bad; but it is arranged in the order other than that in which medical goods and medications are used in practice.

According to the MARCH algorithm (TCCS Protocol), it is always essential to stop massive bleeding at first (apply a tourniquet and/or tamponade the wound), because death caused by it can occur within 3-5 minutes. In this case, the wounded becomes unconscious from blood loss in 45-90 seconds, so he has even less time for self-help.

Then, according to the protocol, one needs to secure patency of airways, close all open chest wounds, examine the wounded for other bleeding, check pulse and breathing (if necessary, start start CPR), check head injuries, prevent hypothermia and only then decide whether painkillers, antibiotics, etc. are needed. Whereas medicines are listed first in the list of the Ukrainian authority.

Another comment from practitioners: the list approved by the MoH leaves a "room for manoeuvre" for the compilers of kits. This, primarily, refers to the choice of the tourniquet. The Ministry suggests putting "a CAT-type mechanical means of haemorrhage control"  in the first aid kits without specifying to which extent the "type" has to be. Following the logic of the Order No. 6, the presence of a windlass rod in the tourniquet is enough to be a "CAT-type device." But the tourniquet is a complex mechanism, which is subject to strict requirements: it must be made of high-quality durable materials, and before putting into operation it must undergo various tests: to ensure it will work and not break (deform) or change its qualities in any weather, hold a relatively constant pressure on the limb (350-300 mmHg) for two or more hours, etc. Therefore, to make this device on a 3D printer, sew it yourself or replace it with cheap Chinese counterparts means to expose the soldier to danger, because he will not have a second chance to apply the tourniquet on the battlefield.

Doctors and tactical medicine instructors unanimously state that you may by no means save on a fighter's medical kit and even more so on the tourniquet. According to the Solomyanski Kotyky’s head of tactical medicine, the 100% safe option today is only to use tourniquets recommended by the TCCC Committee (CAT by the American manufacturer North American Rescue, for example) and SICH-Tourniquet by the domestic company Sich Ukraine.

"Sich is the only Ukrainian manufacturer that can actually replace CAT today. Because since 2015 they have established mass, serial production and over time have proved that they have good tourniquets that sometimes even prevail over CAT. The first samples of SICH tourniquets were also not very good, but as time passed, they considered criticism and improved them. Other tourniquets today are a very dangerous story," Nikolenko said.

Motohelp, a volunteer rescue organisation that has been actively collecting and delivering first aid kits to defenders since February 24, shares the same opinion about the choice of tourniquets. "What do we complete personal first aid kits for the military with? SICH or CAT tourniquets – we do not trust others. We will leave the experiments for after the victory", reads the official website of the organisation.

What should an ideal military first aid kit be like?

After studying the opinions of doctors, volunteers and tactical medicine instructors who are directly involved in equipping first aid kits for frontline soldiers, Mind has drawn up a list of what should be in a modern tactical medical kit for a serviceman.

Optimal configuration of a serviceman's first aid kit:
Medical pouch. A cover made of waterproof materials, a detachable Velcro to enable quick removal of it and immediately rendering aid. Nothing should fall out of the pouch when opened, so a case with many pockets and rubber fasteners will work.
Tourniquet (preferably two: 1 inside the kit, 1 outside – for quick access) to stop critical bleeding from the extremities. A quality one, not used for training, with a clean hook-and-loop fastener. It has to remain on the limb until it is cut off by the surgeon after he has finished treating the wound. Removing or loosening the tourniquet yourself is dangerous!
Marker, waterresistant and dark. For quick recording the time of tourniquet application (on a special strip on the tourniquet or in a visible place on the wounded person's body) and filling in the casualty card (if there is any). The admitting physician will need this information.
Hemostatic bandage and/or thick gauze (dressing) for tamponade, with or without hemostatic agent. Used to stop massive bleeding through creating pressure in areas where tourniquet cannot be applied: armpits, groin, buttocks, neck. The hemostatic bandage is impregnated with a special agent (e.g. kaolin) and contributes to the rapid formation of a blood clot.
Atraumatic scissors. Used to quickly cut the wounded person's clothes or shoes and determine the place of bleeding. They should have a blunt end so as not to damage the skin. Quality tactical scissors are less blunt and allow you to easily cut a jacket, belt or other durable materials.
Medical nitrile gloves (they are stronger than latex gloves). To protect yourself from infections when dealing with someone else's blood. It is better to have two sets of M and L sizes.
Nasopharyngeal airway + Lubricant. Used to maintain patency of airways, particularly if there is a jaw injury or the victim is unconscious. It should be suitable in size and lubricant facilitates insertion of the tube.
Occlusive sticker. It covers penetrating wounds in the chest to prevent air from entering. Ideally, there should be a valve that ventilates the wound. There should be two seals: for incoming and outgoing wounds.
Reinforced sticky tape or a dense wide non-woven plaster. A universal thing. Using the tape, you can improvise a chest seal by covering the wound with any material that does not allow air to pass through and binding it to the victim's body.
ІAn Israeli bandage (6-inch) or other pressure dressing to secure what has already been tamponaded or to arrest non-critical bleeding. A good bandage has a pressure element, an elastic bandage and ears that allow you to fix it at the end, as well as a gauze pad impregnated with hemostatic substances.
Thermal blanket. Used to wrap the injured man and keep his body warm for some time. The lower is the core temperature, the worse the haemorrhage stops.
Additionally, the first aid kit should be supplemented with:
Burn relief gel wipes or bandages. The first aid for burns, eliminating contact of the wound with air, do not stick to it, have a cooling effect. Easy to remove during bandaging a wound.
Shield (pad) for the eye. Protects the injured eye from foreign particles and dirt and additional trauma during bandaging.
Decompression needles. Used to solve the problem of tension pneumothorax.
Pill-pack. A set of pills in a separate box or zip-pack, including an anti-inflammatory, an antibiotic and an analgesic. Consumed immediately after the injury.
Personal drugs. They are stored separately from the pill-pack. These are medicines for chronic diseases, anti-allergic, etc. Important: inform the unit's medic about your health conditions or allergies, so that, if necessary, you can replace the medicines in your pill-pack with safe ones.
Triangular bandage to immobilise your limb for a certain period in case of injury or fracture.
Tablets for water disinfection, alcohol wipes, bactericidal patches.

Generally, the basic rules for the owner of a medical kit are: to be able to use what is in it and to know exactly what is where. It is also important to agree in the unit on a specific (the same for everybody) place to carry the first aid kit and tourniquet for all soldiers. We remind you that aid to the soldier is provided with the means from his kit, so everyone in the unit should know how to get to it as quickly as possible. And, of course, do not economise on its components, otherwise they can fail you at a critical moment.

Reality: What combat first aid kits look like in practice

Having found out what should be the quality of the SIIMKs, Mind requested civil volunteers and a combat medic to tell and, if possible, show us what the kits for defenders are filled with in practice and whether they contain a lot of medicines and medical products of domestic make.

Contents: tourniquet (CAT by North American Rescue), hemostatic bandage (Celox Rapid), dense gauze for tamponade (BlackFront), nasopharyngeal airway with lubricant (North American Rescue), occlusive sticker (Foxseal Vented by Celox), Israeli bandage (Rhino Rescue), thermal blanket (Medi-Inn), eye shield, nitrile gloves, atraumatic scissors, marker, reinforced tape, casualty card (printed by themselves) and a pouch.

In the words of Ivan Nikolenko, the head of tactical medicine at the Foundation, most of these medical products can be easily replaced by Ukrainian alternatives. The foreign-made medicines in Solomyanski Kotyky's first aid kits appeared primarily because they are supplied to the organisation on a non-profit basis.

Nikolenko notes that it is possible to equip the military medical kit with a Ukrainian-made SICH tourniquet by the manufacturer of the same name, for example, instead of the American CAT. The company also manufactures high-quality Israeli bandages SICH Bandage 6". "Since February 24, there have been many new volunteer organisations that make bandages. And this is one of the few things that can be produced right ‘just-in-time’: start and sew. I was sent a few versions of bandages for tests, they were all quite good," he adds.

"We produce hemostatic bandages Krovospas (Research and Development Centre Borey) that have been tested at the battlefield and are even more effective than Celox and QuikClot and are cheaper either. Chest seals, thermal blankets, atraumatic scissors and bandages are manufactured, among others, by Kievguma rubber producer. However, Nikolenko admits that he has not checked the quality of these products and adds that nasopharyngeal tubes from this manufacturer are good, but it is cheaper to buy them abroad (Kievguma airways cost 330 UAH, while they can be bought for 40-180 UAH at foreign manufacturers.)

Eye shields, he says, can be printed on a 3D printer. Nitrile gloves, marker and reinforced tape are no bother to find in Ukraine, and common domestic bandages can be used for dressings and tamponade (although it will be much less convenient, but they will perform their function.) Tactical pouches are produced in Ukraine without any problems, shapes and sizes are different .

As for the pillpack, Solomyanski Kotyky do not put it in their first aid kits, because they believe that it is the task of the unit's medic to complete the SIIMK with medicines. He has to find out whether the soldiers are allergic to certain drugs and instruct them in which case to take the pills. The standard of the Ministry of Healthcare suggests adding 2 tablets of analgesic (Paracetamol 500 mg), anti-inflammatory (Meloxicam 7.5 mg) and antibiotic (Ciprofloxacin 500 mg or Levofloxacin 500 mg) to the kit. All these are produced by Ukrainian pharmaceutical companies, in particular, Darnitsa, Zdorovya, Lekhim, Farmak, Astrapharm.

Contents: two tourniquets (CAT by North American Rescue and DNIPRO GEN 2 from VK Prostir), two hemostatic bandages (Krovospas), tamponade bandage (HDP Medical Supplies), nasopharyngeal airway with lubricant (by private entrepreneur I. O. Ter-Arakeliants), two occlusive stickers (North American Rescue's HyFin Vent), decompression needle (TyTek Medical), Israeli bandage (TacMed Solutions), Coban autoadhesive wrap (Cardinal Health), extra bandage, triangular bandage, thermal blanket (Swiss Safe), nitrile gloves, atraumatic scissors, marker and pouch. Burn relief gel wipes (OpikUn by Zentex company) may be added to the kit if available.

Ukrainian tourniquets DNIPRO GEN 2 (generation 2) are certified, and after having been used in Dubno, they were approved by the chief medical officer, to whom the volunteer hands over medical kits. Meanwhile, it should be noted that some paramedics and tactical specialists, including Ivan Nikolenko from the Solomyanka Kitties, do not recommend using them.

Mind received it privately.

Contents:  tourniquet (SAT by North American Rescue), hemostatic bandage (QuikClot),  nasopharyngeal airway with lubricant, two occlusive stickers (HyFin Vent by North American Rescue), Israeli bandage (Rhino Rescue), thermal blanket (Swiss Safe), 10x12 cm sterile transparent plasters and roll (3M), antibiotic ointment (Bacitracin Ointment), nitrile gloves, atraumatic scissors, marker and pouch.

Mind received it privately.

Includes: two tourniquets, hemostatic napkin (Krovospas), occlusive sticker (HyFin Vent by North American Rescue), bandages, atraumatic scissors, pouch.

Individual first aid kits of the military, as we can see, are equipped mainly with medical products, the purpose of which is to save the life of the injured people until their evacuation from the battlefield. Speaking directly about medicines at the front, it is worth mentioning the medic (paramedic) bags and bunker kits. The latter are a set of medicines from a stationary aid post, but as a shortened list. There are cold medicines, sorbents, medicines for headaches, stomach upset, etc. Medical bags are more specialised for providing emergency care to troopers.

Medical bag: Requirements and practice

The standard for completing a tactical backpack is prescribed in the already mentioned MoH Order No. 6 of January 5, 2017. Nevertheless, each war medic assembles a backpack for himself. The pack contains a lot of consumables and medical products to cover the needs of the unit. "Conditionally, this is a large first aid kit that is equipped in order to provide full assistance on the battlefield to an average of 5 soldiers (a medic simply can not carry more)", says Andriy Dubenko, who assembles packs for combat medics in addition to IFAKs, "It contains, for example, 10 tourniquets, 6-8 bandages. The pack is large, about 40-45 litres and weighs up to 10 kg."

Among the items that are absent from IFAKs, but present in the packs are: syringes, venflons, splints (including cervical), soft stretchers, both abdominal and 8-inch bandages, Ambu bag for artificial ventilation, a set of oropharyngeal airways, saline solutions in plastic, antiseptic and many medicines, including in ampules.

"The medic's pack contains mostly ampoule drugs, almost all of which are of home production. In such conditions, tablet drugs, first, act slowly. Second, the injured men are not always able to swallow pills on their own. Therefore, he must be saved by ampule drugs," Dubenko explains.

Medics, among other things, order from the volunteers the following medications for their packs (sometimes in terms of trade name, sometimes in terms of active ingredient): analgesic Ketolong (Darnitsa), painkiller Caver (Farmak) or Dexketoprofen (Lubnyfarm), hemostatic Hemotran (Farmak) or Tranexamic acid (Lekhim), Tramix (Arterium), antiemetic for blast injury or head injury Metoclopramide (Darnitsa, Zdorovya, BCPP) or Cerucal (Teva), antispasmodic No-Spa or Drotaverine (Darnitsa), steroid Dexamethasone (Darnitsa, Farmak, Lekhim), as well as more specific drugs – Atropine (Darnitsa), Adrenaline (Zdorovya), Bupivacaine (Zdorovya Narodu, Nikopharm), etc.

As can be seen, nearly all drugs are produced by Ukrainian pharmaceutical companies. Volunteers and doctors note that domestic-produced medicines are much cheaper than their foreign counterparts, while being not inferior in quality.

How are medicine and medical device manufacturers involved in preparing combat medical kits?

While preparing the material, we noticed that many doctors and military men speak of receiving kits from volunteers, not from the state. These are often basic versions, which are then completed by chief medical officers and troopers themselves. Therefore, we asked the Ministry of Defense and the Medical Forces Command of the Armed Forces of Ukraine about the centralised supply of tactical IFAKs to the front. No response was received.

Meanwhile, posts about execution of a large government order in this field appeared on the Facebook pages of Sich Ukraine (SICH tourniquets and bandages), Kievguma (nasopharyngeal airways) and Centa Pharm (Hemostatic bleeding control products) at the end of November. "Together, applying maximum efforts, in 4 months we have completed the supply of SIIMK sets under contracts with the Ministry of Defense in full," Kievguma reported in the social network.

Mind asked domestic medicine and medical product manufacturers, represented by the first aid kits and medic packs, about the form in which they provide the products for the army. It turned out that the companies do not assemble first aid kits or packs on their own, but send everything needed directly on request of volunteers, chief medical officers, civil and military hospitals, military units, local and central authorities (both under contracts and for free.)

"We have been cooperating closely with the state since the beginning of the full-scale phase of the war on the strategic challenges facing the country. Thus, since the beginning of this year, we have donated more than 2.2 million packages of medicines to the Ministry of Healthcare, the Ministry of Defense, medical institutions and volunteer organisations. Over 200 organisations have become the recipients," says Gurgen Karapetian, National Hospital Purchases Manager at Darnitsa Pharmaceutical Company. The company, for example, imported 10,000 packs of Celox hemostatic agent to the country at its own expense and delivered it free of charge to hospitals and to the front line at the beginning of the invasion. "At the same time, projects on medicine procurement are implemented for the budget funds of various levels," he adds.

Zentex company whose OpikUn burn relief gel wipes and bandages are popular at the front (the scale of orders can be measured in thousands), has not received direct requests from the Ministry of Defense or the Ministry of Healthcare. The manufacturer has been supplying products to the front since 2015 and does it mainly through volunteer organisations and upon the request of combat paramedics and military units. At the same time, the company underlines that in recent years, its products of specific sizes have been increasingly included in the terms of tender procurement. And since commercial partners often order Zentex products for participation in government tenders, the company assumes their products are supplied at the request of the MoD or the MoH via this channel.

At the moment, the domestic production of Krovospas hemostatic products that are so highly appreciated at the front, is organised exclusively on a volunteer basis. The output is released exclusively for sponsorships and voluntary donations, and the products are transferred for free to the battlefront, as well as to volunteers and charitable foundations that assemble medical kits for defenders themselves.

"Every day we send 10-20 parcels by Nova Poshta postal service to different recipients in the amount of 500 to 2,000 pieces a day. We receive official requests from the military at the unit commanders or combat medics level. We also get orders from volunteers who complete first aid kits as well as charitable foundations," says Igor Tsurupa, representative of the manufacturer.