A 4-year-old in a playground nearly killed by a missile blast. Another child left with shrapnel through his brain. Nicholas Jones reports on the toll of Russia's invasion of Ukraine, and the remarkable effort to help some children get back on their feet.

Before dawn on February 24, the Kutniakh family woke to explosions.

They figured the military was training at a nearby base but then a shocked relative called.

"He said, 'It's the beginning,'" remembers Maksym Kutniakh, a farm supplies salesman who lived with his wife and son in Mykolaiv, a city near the Black Sea in southern Ukraine, when Russia invaded.

"We couldn't believe it."

They moved about 100km east to their parents' village of Tamaryne, but fighting intensified and the family decided to flee and join relatives in Italy.

Flags made from white bed sheets were hung from two vehicles, and at 8am on March 13 they set off on country backroads that they and neighbours had used without incident in the preceding days.

Maksym drove in front, with his wife, Liubov, and 5-year-old son, Mykhailyk, in the back. In the following car were Liubov's mother, Svitlana, and 17-year-old brother, Leonid.

At a fork in the road they chose the more off-road track, figuring it was quietest and therefore safest.

It took them straight into the path of a Russian military truck, parked about 80m ahead.

The Renault vehicle which was driven by Maksym Kutniakh when Russian soldiers fired upon the vehicle with grenades and machine guns. Photo / Supplied

Soldiers jumped from the vehicle's cabin, and one aimed a grenade launcher.

Maksym yelled for his wife and son to get down. The explosion shattered the Renault Duster's windows, and was followed by machinegun fire.

He shouted, 'We're civilians, we're civilians', but the shooting continued. Maksym backed up the SUV to the left, not wanting to reverse into the following car or tip into a ditch.

Bullets ripped through the vehicle, striking his lower leg. He pulled across the road to execute a three-point turn.

His son screamed, but Liubov was silent. She'd covered Mykhailyk with her body in the moments before a bullet pierced her forehead, likely killing her instantly.

Mykhailyk Kutniakh's mother died whilst shielding him with her body. Photo / Milan Jaroš

The machinegun fire continued as Maksym reached back blindly with one arm, while steering with the other.

"I realised she wasn't moving. I wasn't sure if she was alive, but I knew the damage was severe," he told the Weekend Herald, speaking through a translator.

"I saw the second car without windows and with no people visible, and knew they were probably killed."

Shrapnel had shattered Mykhailyk's skull and lodged in his brain.

Doctors at a nearby medical centre found brain particles on his head, but concluded these were probably his mother's.

Maksym Kutniakh with his wife Liubov, photographed in happier times before the Russian invasion of Ukraine which took her life and badly injured their son Mykhailyk. Photo / Supplied

The injury was far beyond their capabilities, but getting to the regional hospital in Mykolaiv was treacherous. At one point the group, which included his grandmother, Olena Kutniakh, had to cross a blown-up bridge on foot.

"I carried Mykhailyk, and a nurse carried the infusion pump," she recalls.

"We met a column of military vehicles advancing towards us. 'What is meant to happen will happen,' I thought. Later we were able to see a Ukrainian flag on one of the vehicles."

Her grandson's head was cut "as if with a blade" and bled constantly.

"The bandage didn't really help stop the bleeding. When we arrived at Mykolaiv Hospital all my clothes - a jacket, sweater, everything all the way to my knees - were soaked in his blood."

Doctors told the family to prepare for the worst. They operated to remove the biggest pieces of shrapnel, but the 10-15 cm wound couldn't be properly closed because the surrounding skin had been burnt.

Mykhailyk Kutniakh with his father Maksym and grandmother Olena in Prague. Photo / Photo / Milan Jaros

Olena's memory of those touch-and-go days is mostly wiped by the trauma. She wasn't allowed in intensive care so she approached every staff member coming and going for news.

"Finally a doctor told me it would be all right, because 'You've got a fighter'."

Further assurance came when staff reported he was demanding the essentials: food and cartoons.

"Doctors had said earlier that even if we save him, he could be like a vegetable," his grandmother says. "So imagine what news it was for me at that moment.

"He requested food that he wanted, and grimaced, "Neeh", when offered something he didn't want. That was the moment when I thought: 'Here is our Misha!'"

However, they were all still in danger. Mykolaiv was almost encircled by Russian forces, who regularly shelled the hospital. The family spent three days in a bomb shelter.

"It was just devastating," Olena says of the hours underground. "The walls were shaking and shaking. At some point, we couldn't stand it anymore."

A photo from the time shows Mykhailyk being pushed in a wheelchair by his grandfather, during one of the rare occasions they were allowed outside. The windows in the hospital block behind them are blown out by the force of explosions that also damaged the main entrance.

Mykhailyk Kutniakh, 5, is wheeled outside of Mykolaiv Hospital by his grandfather Volodymyr, during a rare respite from regular shelling attacks on the hospital by Russian forces. Photo / Supplied

The family didn't hesitate when a doctor offered to evacuate Mykhailyk to Saint Nicholas Pediatric Hospital in Lviv, a city near the Polish border relatively untouched by Russian missiles.

It was there that his case came to the attention of Iryna Rybinkina, a cardiothoracic anaesthetist who worked at Auckland City Hospital when the full-scale invasion began.

Rybinkina soon resigned and moved to Lviv to lead the work of her NGO, Smart Medical Aid, which has delivered supplies, training and support to help victims of injury and trauma in Ukraine since 2014, when conflict erupted with Russian-backed separatists in the east of the country.

The NGO relies on support from around the world, including New Zealand. Musicians from the NZ Symphony Orchestra also held a special concert to raise money, and Kiwi doctors volunteered to help triage supplies from the organisation's Lviv warehouses and to teach basic life support.

When Rybinkina, who was raised in Kyiv, saw Mykhailyk's CT scan she knew he needed highly-specialised, long-term care.

Dr Iryna Rybinkina was working as a cardiothoracic anaesthetist at Auckland City Hospital when the full-scale invasion began. Photo / Supplied

Her team has worked with DavepoMedevac, a Prague-based private ambulance and emergency care company, to deliver donated supplies to Ukraine, and to evacuate injured children (and their family members) to the Czech Republic, for world-class treatment and care.

One of the company's paramedics, Radan Doubrava, happened to be in Lviv at the time, after one of several trips to Ukraine to drop off ambulances and desperately needed medical supplies.

Doubrava, who as an expert in combat lifesaving has led training in conflict zones around the world, says when he met Mykhailyk in Lviv, "he was quiet in a way that was not normal".

"We brought him some sweet cakes … you could see in his eyes, something terrible had happened. I have two sons, it was not nice for me [to see].

"That look on his face I saw in my nights for a long time."

"That look on his face I saw in my nights for a long time," said Radan Doubrava, a paramedic with private ambulance and emergency care company DavepoMedevac. Photo / Nicholas Jones

It took 12 hours to drive Mykhailyk by ambulance to the University Hospital in Motol, Prague, one of the largest hospitals in Europe and a leading centre for specialities including neurosurgery.

Thankfully, the trip went well.

"Such transports can be easy - nothing will happen, like normal commuting," Doubrava says. "But on the other hand, he had a hole in his skull [and] was leaking cerebrospinal fluid … he could deteriorate fast, he could have seizures - you name it, many complications could have happened."

Mykhailyk has had three successful operations in Prague, including to remove more splinters of shrapnel, and plastic surgery to cover the wound with skin. Another major surgery looms, when an artificial plate will be implanted to help reconstruct the growing skull.

He has no brain damage or significant developmental issues and is back to his energetic, curious self - reading books about dinosaurs, animals and insects hundreds of times over, and playing football with his dad every evening, no matter the weather.

"Our Pele," his grandmother says.

A life shattered in a playground

I travelled to Prague to meet Mykhailyk, as well as another young patient transported after the intervention of Smart Medical Aid.

Dmytryk Radkevych was wounded in Kyiv the day before his family planned to drive across the border to Romania and then fly on to Turkey.

It was March 17. Russian forces were near the capital, but the family's part of the city was quiet, with no air-raid sirens or signs of danger.

The 4-year-old went with his father, Oleh, to get groceries.

Coming home, he ran to a playground and took a few happy swings, before the world exploded; three Russian missiles struck nearby.

Video shows a Russian missile strike hitting a playground in Kyiv, Ukraine, on March 17th. Video / Supplied

Oleh carried his son's body to a nearby building. Blood poured from a wound on the little boy's back, soaking clothes splattered with burnt flesh.

Dmytryk's eyes closed as they waited for an ambulance.

"I begged him not to sleep, because I could not imagine what would happen next," his mother Nataliia says. "I begged him until the ambulance arrived at the hospital."

Surgeons removed shrapnel from the wound, which was about 18cm by 10 cm, and applied a vacuum-assisted closure (VAC) device, which decreases air pressure on a wound to aid healing and can reduce swelling, bacteria, drain excess fluid and help pull the wound edges together.

Dmytryk Radkevych was evacuated to Prague after being badly wounded in a Russian missile strike. Photo / Supplied

Dmytryk's spinal cord was damaged, he was leaking cerebrospinal fluid, three ribs were broken and his hip area was badly swollen.

The family took the offer of evacuation to Prague, but had a week-long layover at a hospital in Lviv.

Proper medications weren't available, Nataliia says, and there was one working elevator to get all patients, staff and family to the bomb shelter when air-raid sirens sounded at least a few times daily. Dmytryk was moved on a stretcher.

Dymytryk Radkevych being treated by Dr Iryna Rybinkina. Photo / Supplied

Finally they were taken across the border by a DavepoMedevac ambulance. A video of the transfer shows a scared boy, with a soft toy beside him, surrounded by masked medical staff and being comforted by his mum.

That first night in Prague the 4-year-old finally slept better, because he got proper pain relief.

The VAC system stayed on for four weeks and then surgeons completed complex surgery to bring together damaged back muscles and stop the cerebrospinal fluid leakage. He has had major skin grafts.

"I begged him not to sleep," said Dmytryk's mother Nataliia Radkevych after her son was struck by shrapnel. Photo / Eva Korinkova

Dmytryk lay for six weeks on his belly, before being shifted on to his back for a week.

Soon after that, he tried to push himself up in the hospital bed - a breakthrough moment - and later he took his first tentative steps while leaning on a wheelchair. (His mother had been too scared to ask doctors if her boy would walk again; "I was just happy that he was alive".)

When I meet them at a cafe in Prague's Old Town he runs around outside, and there's no obvious sign of his ordeal.

However, he still needs intensive rehabilitation and psychological support. The latter is helping bring back the boy she knew before the missile strike, Nataliia says.

"He had changed into a completely different person … now, he is more joyful and smiley."

'Here, no child is safe'

At least 359 children have died as a result of the Russian invasion, Ukraine's Prosecutor General says, with more than 700 injured. Those numbers don't include casualties in Russian-occupied areas or from near the frontline.

Russia denies targeting civilians and claims the war is a "special military operation" to "deNazify" Ukraine.

Smart Medical Aid has helped evacuate a handful of children to Prague and elsewhere in Europe. However, if possible the preference is to keep patients and their families in Ukraine.

The risk of death and injury isn't confined to areas near conflict zones. Russia regularly fires missiles across Ukraine, killing civilians thousands of kilometres from the frontlines. Last month 23 people died after an attack on the central Ukrainian city of Vinnytsia, including a 4-year-old girl with Down syndrome who was returning from speech therapy.

Rybinkina's husband and children, aged 3 and 9, are living in his native Netherlands. She misses them badly, she says, "but I know my children are safe".

"I know that no missile will fly into their playground. And here, no child is safe."

Iryna Rybinkina with her husband and children who are living in the Netherlands. Photo / Supplied

Both Dmytryk and Mykhailyk are some of more than 375,000 refugees fleeing Ukraine who have been granted temporary protection by the Czech Republic, the biggest number per capita and which allows access to free healthcare and education, and the ability to work.

A staggering 6.3 million refugees from Ukraine have been recorded across Europe, the UN says, with millions displaced within Ukraine. Some 3.7 million Ukrainians have applied for temporary residence in another country.

Blue and yellow flags hang from buildings around Prague, and a huge banner at one end of the famous Charles Bridge demands, "Hands Off Ukraine, Putin!"

Dmytryk Radkevych, 4, was badly wounded when a Russian missile strike landed near the playground he was in, on the outskirts of Kyiv, Ukraine. Photo / Nicholas Jones

At nearby Letna park, inline skaters and dog-walkers pass a busy exhibition displaying Russian tanks and armoury destroyed in the war and transported across the border to tour Europe, with people urged to donate to help Ukraine by scanning QR codes.

However, some municipal leaders have complained about refugee numbers in the city compared to outside the capital, and here and elsewhere in Europe social media is poisoned with disinformation about refugees and the benefits they supposedly receive.

"Unfortunately, in all nations, you have a certain percentage of idiots," Doubrava says of the far-Right opposition to helping those displaced from Ukraine. "Some of those idiots are more visible on social media."

Dmytryk's father, Oleh, couldn't go to Prague because of a wartime decree banning most men aged 18 to 60 from leaving Ukraine, in anticipation that they may be called to fight. Maksym, Mykhailyk's father, received a widower's exemption.

Nataliia and Dmytryk have been given an apartment to live in and other support, but life in a strange land isn't easy.

After our interview Nataliia is attending Czech language lessons. There's a nearby creche, but Dmytryk often tags along because he feels safe only with her.

Dmytryk Radkevych is in Prague recovering from severe back wounds incurred when a Russian missile struck a playground where he was playing in his home town. Photo / Eva Korinkova

Mykhailyk's family are also homesick, and eager to return once he's recovered, and if the security situation allows.

There they'll visit Liubov, who was buried in Tamaryne without her husband, son or mother present.

She and Maksym met at university.

"She was not only a woman I loved, but a real friend," he says. "We could spend hours discussing a lot of business topics, films and so on.

"It feels like I'm cut off by half."

Mykhailyk Kutniakh, 5, with his beloved football, photographed in Prague, where he is recovering from a severe brain injury. Photo / Supplied

Mykhailyk also suffers. He and his mum were inseparable.

"He remembers her often, especially when he's sad. We are working on this with the psychologist," Olena says.

"At first, he was saying his mother was waiting for him at home. Now he understands she is 'in the sky'. It was the way we had to explain it to him.

"Sometimes, he may say, 'Do you remember that before the boom…' He also never says blood, he says 'red' instead. Maybe he has some memories."

Nicholas Jones reported from Prague with the aid of an nib senior health journalism scholarship.

• Further information about Smart Medical Aid and how to donate can be found here.

- Nicholas Jones, NZ Herald