Every person living in a nation at war is either a civilian or in the military. There is an undeniable mental wall between the two. Pain, habit, and bad manners can all stand in the way of empathy. Sometimes an offhand remark along the lines of “You’re so young, who’s gonna want to marry you now?” can hurt a soldier who has lost a limb more than an enemy bullet. As if marriage is the only sure way to happiness.

People who have lost limbs or eyes, suffered multiple fractures, or have post-traumatic stress disorder (PTSD), all find themselves in rehabilitation centers. These centers create a bridge between the injured soldier and either their military unit or civilian life. Medical experts are there to facilitate this transition.

Suffering with Compartment Syndrome for 240 hours

In present-day Ukraine, a soldier’s diagnosis speaks volumes about their physical and mental strength. Ihor (a pseudonym), 40, has the following entry in his medical records: “Has suffered compartment syndrome for 240 hours.” At first, doctors thought it was a typo. Compartment syndrome occurs when blood stops flowing to a limb. Damage occurs as a result of tissue and nerve compression under the tourniquet and the accumulation of blood waste products in the compressed part of the limb. Ideally, the tourniquet is applied for several hours (one hour in winter and one-and-a-half to two hours in summer; in some cases, a tourniquet can be applied for a longer period of time, but not more than two to four hours), during which time the injured person should be taken to a medical facility.

Ihor’s foot was torn off in an explosion last winter. He applied a tourniquet to his leg, as he was trained to do, and then spent 10 days in a trench repelling a Russian attack. With him in the trench was another injured soldier whose arms and legs were also wounded. Ihor didn’t only manage to survive – he also saved the life of his brother-in-arms. Ihor’s leg has since been amputated; the foot Ihor didn’t lose in the explosion has also been amputated as it suffered severe frostbite.

I first heard about Ihor from Olena Tarakanova, a doctor specializing in physical rehabilitative medicine and the director of the Odesa rehabilitation center of the nationwide Recovery network. She smiles when she talks about Ihor and says that talking to him she always feels lighter at heart: “He’s always upbeat and cheerful; he’s got a great sense of humor and jokes a lot. He’s always busy. Each patient follows a different rehabilitation program, but they also all hang out together, take trips to the beach, for example, or go to jiu-jitsu or archery practice or to the shooting range [these are all activities offered by groups of volunteers – ed.]. Ihor is someone who’s up to anything.”

To ensure a full recovery, it’s important to start rehabilitation as early as possible. Today, 12 Recovery rehabilitation centers are operating in Ukraine.

Each center is equipped with state-of-the-art rehabilitation equipment that targets many types of functional disorders, including those caused by blast injuries and gunshot wounds. There are also rooms fitted for occupational therapy. Some of the equipment incorporates the use of virtual reality (VR), which enables rehabilitation professionals to get feedback from their patients.

Each patient’s rehabilitation is overseen by an interdisciplinary team of professionals headed by doctors specializing in physical medicine and rehabilitation, or physiatry. Each team usually consists of three to five people: a physical medicine and rehabilitation expert, a physiotherapist, a speech therapist, a mental health expert and an occupational therapist. Experts in other fields might also get involved when needed.

Soldiers are treated at Recovery centers free of charge and can spend from two weeks to three or four months there. The most common injuries among Recovery patients are gunshot wounds and mine-blast injuries.

   

 1 Prolonged tourniquet application can lead to the development of compartment syndrome, a condition characterized by increased pressure within a muscle compartment, resulting in tissue damage and potential loss of limb function. After blood flow is restored in the limb, all tissue decay products enter the bloodstream and can cause kidney damage, shock, and death. Due to the high risks in such cases, doctors are often forced to amputate the affected limb much higher than the affected site, which complicates the process of fitting prosthetics and rehabilitation. Saving a life sometimes means condemning a person to a lifetime of impaired daily functioning. Proper training for combat and evacuation medics, effective emergency and planned reconstructive surgeries, and cooperation across medics and rehabilitation teams can increase the chances of saving a life.

Being closer to flowers

The goal of most rehabilitation programs today is to help patients reintegrate into society. All patients are different: some are enthusiastic about recovery, while others seem reluctant to recover. Most are enthusiastic, however. These are people who have someone or something in their lives who motivates them and makes them want to return to an active life: a wife or husband, kids, parents, goals, plans, or something they love. In other words, a will to keep going no matter the circumstances. The people around you give you energy, and having work that you like can be a source of meaning and excitement. Another quality shared by people who are enthusiastic about recovery is having a wide range of life experiences. They have experienced loss and failure and managed to pick themselves up. It can often be harder to work with someone who’s 20 and doesn’t have that experience.

There are others: people suffering from existential crises, those who have fallen into despair and shut themselves off from the rest of the world. They’re tired of hardship. They don’t want anything anymore. Two people may have suffered the same type of injury, but their rehabilitation will depend on their temperament, flexibility, and their ability to shift perspective.

In her book The Gift, American psychologist Edith Eger who worked with Vietnam War veterans, tells the story of two soldiers. Both were in a terrible state, suffering from similar symptoms, and likely to spend the rest of their lives in wheelchairs. One was angry with God and the government, and kept asking: “Why did this happen to me?!” The other smiled at Eger when he first met her and said: “Doctor, I’m using a wheelchair now, and you know what? I can look into my kids’ eyes much better. I can look at the flowers from up-close.”

Things worth recovering for

Modern rehabilitation is a patient-led process in which the patient is not a passive observer but an active participant. They first talk to the doctor who oversees their rehabilitation team, and then to each of the experts on the team. The team then works with the patient to set realistic goals that take into account the patient’s life goals, support systems, personality, and the state of their health. How motivated the patient is is one of the most important factors in this process.

Tarakanova believes that rehabilitation goals have to be clear and realistic: “When someone is asked to do 20 push-ups today and 30 pull-ups tomorrow, they have to know what the point of it is. We’re not a sports camp. We tell people: ‘You’re doing this so you can have your prosthesis fitted sooner, so you can start walking. Why do you want to walk? Because you want to be able to pick up your kid from school, to drive, to go to work.’ These are things that motivate people and give them the strength to keep going.”

People can train muscle strength,endurance, range of motion, and balance at a special gym. They work with doctors to ensure their stump is formed in a way that would make fitting a prosthesis not just possible but comfortable. Amputations are often carried out on the front, in extreme circumstances, which is why soldiers’ stumps are often a lot more complex than those people are left with after routine surgeries.

The rehabilitation team also works on muscle tone, because your muscles have to be very strong in order for you to be able to use a prosthesis. It’s thought that the earlier you start wearing a prosthesis, the more likely you are to be able to walk without crutches. Using a prosthesis is difficult because it’s so different from how you would use your limb. With a leg prosthesis, you have to shift the weight of your body onto a certain part of your prosthesis, to learn how to maintain balance. Soldiers learn how to walk on even ground, then to traverse obstacles, to go up and down the stairs, and use a ramp. They practice everyday. At first, they hold on to support bars, then they practice using two crutches, then one, and then a cane. 

The rehabilitation process can be easier for someone who was athletic and did sports prior to their injury: these patients generally have a better understanding of what different exercises are targeting. They have a better sense of their body in space. But they are also often overachievers, which isn’t necessarily an advantage during rehabilitation, when overexertion might cause complications of its own.

Doctors are the most challenging patients. Physiotherapists and rehabilitation doctors often feel like they have to prove their mettle to them.

Patients who have had their lower body paralyzed have other goals: in addition to learning how to use a wheelchair and being self-sufficient, they have to work to restore their pelvic function, because being able to go without using a catheter or an adult diaper makes a real difference to your quality of life.

I ask Tarakanova: “Can wheelchair users have sex?” She smiles: “That’s the first question the guys ask after they get injured. ‘Is everything down there okay?’ Yes! They can [have sex]. Lots of our former patients get married.”

Looking in the mirror as pain relief

Every patient in a military hospital could probably write a book about different types of pain. The body of a person who has sustained a wound is a body in pain. Phantom pain is something that people who are not experts in medicine really struggle to understand. On the one hand, this pain is real, but on the other, the limb where someone experiences this pain is gone. This is different from the pain someone might feel in their stump. Doctors are now largely able to identify what type of pain a patient is experiencing in any given situation, how intense this pain is, and what type of pain relief is appropriate. In addition to painkillers, doctors can also prescribe antidepressants and/or non-medical approaches, such as mirror therapy.

Tarakanova says that phantom pain occurs when the brain fails to recognize that a limb is missing. How could it be that it was there and now it isn’t? Severed nerve endings don’t function the way they should, causing a person to experience pain in a missing limb. During mirror therapy, a doctor places a box with a mirrored surface, in front of the patient. The patient places an intact limb in front of this mirror – for example, their right arm. The brain registers the reflection of this right arm as the left arm, which is in fact missing. This exercise helps reduce and eventually eliminate phantom pain.

No one knows why this works. A possible explanation put forward by researchers suggests that the illusion of the amputated limb causes the brain to stop sending pain signals to the phantom limb. Mirror therapy works for people who have lost one limb.

Virtual reality therapy is sometimes used to fight pain if a person loses both of their limbs. The patient puts on a VR headset and tries to manipulate their missing limbs, for example picking up or lifting something.

“Do you explain to them what’s happening?” I ask Tarakanova.

She nods. “Yes. Psychology recognizes that patients’ subjective experiences of disease might be different from reality. Patients might need to have what really is happening explained to them, because trauma-related sensations are new to them and can feel strange and incomprehensible.”

Tarakanova says that all of the center’s patients are suffering the effects of contusions; many experience hearing problems. These contusions are more intense than what people experienced during military conflicts in the previous century. Soldiers on the front might suffer several contusions and concussions a day. Constant shelling severely damages their eardrums. All this has an effect on their spatial orientation and memory. Some people get lost in the hospital’s hallways.

The symptoms of contusions fluctuate from day-to-day: one day it’s a headache, another day dizziness and fainting, another still you forget the conversations you had 10 minutes before. These fluctuations create a sense of uncertainty. You don’t understand what’s going on. The rehabilitation team has to be able to explain to you why you have a headache or feel like you’re losing your sight and hearing. They have to tell you what’s going on and set out a plan of action that will help you achieve your rehabilitation goals. Then it gets easier, because you regain a sense of control over what’s going on.

Inaccessible reality

Accessibility remains a big issue in Ukraine, in contrast to EU countries, which have made great strides towards creating accessible spaces. Using a wheelchair on the street, or to enter and exit buildings, requires feats of balance.

“The goal of our work is not to have someone we’re working with master a set of skills and then spend the rest of their life sitting at home,” Tarakanova says. “We want people to live active lives. [In Ukraine] random people on the street are often unknowingly insensitive; they just don’t know how to behave around people with visible injuries. They say things like: ‘Oh poor child, you’re so young, why did you join the army?’ Others just ignore people with disabilities. That’s why we take the guys [undergoing rehabilitation] who don’t want to leave the hospital on their own to the store [or other public spaces]. They need to reintegrate into society.”

This is how it goes: a physiotherapist gets a group of five patients together and takes them out for a coffee. This forces the guys to navigate the streets on their way there, even if they don’t want to. Once in the café, they have to reach for their coffee cup and add the sugar. It can be a real challenge. Just months ago, these people were able to make themselves a coffee, and now here they are, dropping things, struggling to reach the sugar from their wheelchair – they spill things, they get mad. They have to have these experiences. It’s good to experience these things when there’s a professional nearby, someone who can explain how best to grab the coffee and add the sugar, or how to reach for something from a shelf in a store, or how to respond to people’s inappropriate questions or remarks.

“I think I’d offer to help someone like that. Or should I not?” I ask Tarakanova.

“Offering help is alright,” she agrees. “I tell all of our staff that they have to first ask whether someone needs help. It goes for people with visual impairments too. If we see that someone on the street is blind, we should ask them if they need help. Some of our patients complain that random people on the street take them by their elbow and ‘help’ them get somewhere they weren’t even going in the first place, when they were just trying to find their bearings and ask where something was.”

Interviewing people is difficult these days. Sometimes it seems like the person you’re interviewing is about to start crying. One moment they’re laughing, and the next it looks like they’re about to cry. Interviewing is like walking a tightrope. And you, the journalist, share a psychological reality with the interviewee, so you’re more aware of your interlocutor’s emotional state. At least that’s how I feel. Emotions wash over Tarakanova’s face like waves over the shore. The Recovery center she manages is right by the sea.

Tarakanova says that all recovering soldiers struggle with sleep. They’re not normally given very strong sleeping pills, as they need to be able to wake up and go to the bomb shelter in the event of an overnight air-raid. She talks to me about cases when rehabilitation doesn’t work, when someone can’t be helped. About a patient who learnt how to get into the wheelchair from his bed but didn’t want anyone to see it. About a 6’6’’ guy with serious fractures that no rehabilitation center could help – until he found himself in Odesa. One day he was well enough to be able to go get himself a pair of sneakers, a victory for the entire rehabilitation center’s staff. As Olena talks, I try to imagine what size sneakers this guy wears. I think that he’ll remember that pair of shoes for the rest of his life. And I hope that he’ll wear-out pair after pair of shoes in a free and peaceful country.