Ukraine’s treatment landscape
We speak to medical staff on the ground to discover the unique challenges of delivering healthcare in a warzone and what the future needs of the population might be
Andrii Vilenskyi was working as an obstetrician and CEO of a hospital in Kyiv when the war broke out in Ukraine in 2022, with airstrikes just 12 kilometres from his workplace.
“We heard explosions every hour, but the facility wasn’t damaged. We started to work as a non-profit hospital from the second day of the war because the Russian military forces captured Vorzel [a northwestern outer suburb of Kyiv], where the government-run hospital for pregnant women was. Closing our hospital wasn’t an option because we had two premature babies who weighed just one kilogram who needed oxygen support and artificial ventilation. We created an operating theatre in the basement shelter,” Andrii remembers.
Since then, the country has dealt with huge amounts of traumatic injury and tackled the logistical difficulties of treating and transporting those on the frontline.
“The main task for the doctors near the frontline is to save a life,” states Andrii. “There is a lack of first aid knowledge in the population. People use tourniquets for hand or lower-arm injuries, which need checking every one or two hours, but sometimes the evacuation route is very long and at the end of this route the soldier has lost their arm due to lack of care in transit. We have a lot of amputations above the elbow, which are very complicated cases.”
There have been some great innovations and lateral thinking (see box), and workers were drafted in to help hospitals handle mass casualties. Staff from Médecins Sans Frontières (MSF, also known as Doctors Without Borders) share their expertise on how to triage patients and treat the most severely injured first, using a document that asks a set of simple questions that assigns patients to colour categories depending on how severe they are.
Similarly, staff from frontline medical aid charity UK-Med have been helping to triage patients. “This can be really difficult!” says Hailie Uren, Ukraine Hospital Manager. “In the hospitals we work within, there may be a bus that arrives and unloads the patients all at once, and the turnover of patients is extremely fast. It is a priority to medevac patients as quickly and as safely as possible to tertiary facilities further west. Essentially, we work with standard triage principals, which not only depends on the acuity of the patient, but available team members.”
The biggest challenge, Hailie reports, is uncontrolled infections due to antimicrobial resistant bacteria. “Prior to the conflict, Ukraine already had an extremely high incidence of Multidrug Resistant Organisms, and this has been further exacerbated by the conflict. UK-Med has brought in a multi-disciplinary team to work with our Ukrainian colleagues to face this challenge. Our surgeons are working to thoroughly clean, stabilise and close patient wounds. Our nursing team are teaching wound-care principles. Our microbiologist, IPC specialist and clinical pharmacist are working together to support the rapid identification of the bacteria causing infections. The problem is simple: the war-wounded cannot be rehabilitated unless they can undergo reconstructive surgery. The patients cannot undergo reconstructive surgery unless they are free of infection.”
This flow of patients from point of injury through to rehabilitation and reintegration is termed the ‘Trauma Pathway’. “The pathway aims to involve various healthcare professionals working together to ensure the best possible outcomes for the injured individual,” explains Hailie. “Getting the war-wounded as quickly and as safely through the Trauma Pathway is the strategy of UK-Med Ukraine’s country programme. Damage control resuscitation (DCR) and damage control surgery (DCS) is the first step of a really long journey for the wounded and getting it right the first time significantly influences long-term outcomes for the patients. Our approach to supporting Ukraine is to share learnings and techniques to minimise the risk of complications, improve the chances of survival, and allow for subsequent definitive surgeries and optimal patient outcomes.”
One such subsequent surgery is the prosthesis offered by Andrii and his team. Since the outbreak of the war, Andrii’s focus has switched to dealing with the aftermath of war injuries. After offering advice in a consultative capacity, he joined Superhumans as Medical Director in November 2022, a charity which provides prosthetics to those injured in battle, whose mission is to “turn Ukraine into a country of superhumans instead of a country of traumatised people”.
The first Superhumans Center is in Lviv and is a one-stop-shop for amputees, with prostheses manufactured in an in-house laboratory, a swimming pool and equipment for physical rehabilitation, and psychological support all under one roof.
“We decided to connect all the services an amputee patient needs in one place. We build multidisciplinary teams with the patient at the centre, so they are involved in the decision-making process with specialists working together,” explains Andrii. “This is a new model for Ukraine, where services for prosthetic procedures and rehabilitation are divided between ministers. For example, the Minister of Health is responsible for rehabilitation and the Minister of Social Affairs for prosthetic procedures. But patients want a multidisciplinary team and it makes sense.”
This innovative way of treating the injured puts patients at the heart, which Superhumans will continue to do as it expands. The plan is open five centres across Ukraine, with the second in Kharkiv.
“We must move the services to the patient because distance is sometimes a barrier for getting the prosthetic and rehabilitation procedures,” says Andrii. “It’s very complicated for us because lots of medical facilities were destroyed. We are looking for the best solution.”
To find out more about Andrii’s work, visit superhumans.com/en
The hospital on tracks
In February 2022, MSF expanded its humanitarian activities in Ukraine, with a focus on support for people living near the frontline, where the humanitarian and medical needs were most acute.
MSF transformed a Ukrainian passenger train into a moving hospital on rails, evacuating people on the frontline while providing essential healthcare and treating traumatic injuries on board, eventually delivering them to hospitals in Lviv. The train was equipped as a basic hospital ward, with beds and machinery, accompanied by a team of nine MSF medical staff.
Yasser Kamaledin, Project Co-ordinator, recorded a video diary at the time: “We’re going to pick up some war wounded and other seriously ill patients, stabilise them on the train, and after a 20-hour journey we’re going to disembark them in Lviv in the west of Ukraine. This train is unique. It was developed specifically for the context here in Ukraine. We have to remember this is still a very active conflict, where transporting a big number of patients over a large distance can be very insecure. Over the first six to seven weeks, we managed to evacuate 547 patients.”
Dr Albina Zerkova, another Project Co-ordinator, remembers: “At the beginning, we had a less specialised train with just a few team members and less equipment. After one month, we got a more medicalised train with enough staff and equipment according to the needs we learnt from the initial train. The oxygen production carriage has an oxygen concentrator, which can provide enough oxygen for the five ICU beds. We also have another 20-26 equipped beds and extra capacity with regular sleeping wagons. We have monitors, ventilators, infusion pumps and diagnostic equipment such as an ECG machine, ultrasound machine, some blood analysis machines and the medications we need.
“Patient numbers and needs are going down because the healthcare system in Ukraine has adapted. We’ve had a good number of ambulances donated, which has increased the capacity of the national ambulance service, and we have increased the capacity of the hospitals. Many doctors who left the country at the beginning of the conflict are coming back to their hometowns, too.”
The teams evacuated and treated more than 2,500 patients onboard the train in 2022.
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This article was taken from the September 2023 edition of FORTIS magazine.
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This article was written for the September 2023 edition of FORTIS magazine; a forum for the NHS to share ideas, innovations and case studies. To read the publication in full and access digital copies, visit FORTIS magazine. FORTIS magazine is free for NHS change-makers and leaders and is available as a print or digital copy. FORTIS magazine is managed and owned by Health Spaces Ltd.
