Doctor Describes War Medicine Training in Ukraine

France — On October 23, a war medicine training mission organized by the French NGO Mehad got underway in Ukraine. Its goal was to train 17 Ukrainian physicians in emergency ultrasound. Medscape took a look back on this expedition with Mehad’s training director Raphaël Pitti, MD. In addition to being an associate professor of emergency medicine, he is an anesthesiologist and specialist in war medicine.

Mehad, formerly known as the Union of Medical Care and Relief Organizations France (UOSSM France), is a health and international solidarity NGO based in Paris, France. It was founded in 2011 by a group of physicians who wanted to bring healthcare to populations affected by the war in Syria, as well as in neighboring countries. The NGO has set up a training center in Lviv, Ukraine, where it now trains Ukrainian physicians in war medicine techniques.

With so many victims coming to the hospital, clinicians must follow a structured approach. This approach starts with triage, where individuals are categorized based on their particular treatment needs. The next step is stabilizing the patients, especially when they are in a life-threatening condition. Stabilization involves resuscitation measures, life-saving surgery, and what is called “war surgery” or “damage control war surgery.”

Conducted in partnership with La Chaîne de l’Espoir (the Chain of Hope), this training project is intended for rescue workers, physicians, surgeons, and nurses at hospitals that, since the country was invaded by Russia on February 24, have found themselves pulled into the battle.

Because the effects of war are not only physical, but also psychological, Mehad also offers training to Ukrainian psychiatrists and psychologists on how to treat psychological trauma in an emergency setting.

Medscape French edition had a wide-ranging discussion with Pitti, who recently returned from Ukraine.

Medscape : Until now, Mehad has mainly operated in Syria. What made you decide to train caregivers in Ukraine?

Pitti: Indeed, over the course of the last 10 years, we’ve opened four training centers and trained more than 30,000 caregivers in Syria. When the war broke out in Ukraine, we looked at our 10 years of experience in Syria and our knowledge of Russian war strategies and we put forth the idea of establishing a training center to help our Ukrainian colleagues. We knew that this would not be a conventional war, with armed forces facing each other in battle — the type of thing that the Ukrainian military hospitals were able to handle, having been prepared for it since 1994. What they were not prepared for, however, was the kind of war this has turned out to be — one in which civilian hospitals would be targeted by Russian bombs.

Medscape : In what ways is the war in Ukraine like what happened in Syria?

Pitti: The war in Ukraine, as in Syria, is an urban war that directly impacts civilian hospitals. It’s a total war, with the bombings making no distinction between civilian populations and military populations. Encirclement and siege, as we saw in Syria, leads to hospitals having to function in a broken-down situation where there’s a lack of resources and staff, because, due to the intense fighting, caregivers either fled, when they were able to, with the other civilians or they were displaced. Ensuring a certain quality of care in the hospital facilities thus becomes complicated, and it’s necessary to train the staff, not only in terms of illnesses, triage, implementing protocols — transfusion, etc — but also getting surgeons up to speed on war surgery and training the nursing staff.

Medscape : Where in Ukraine did you set up your training center, and how did you go about it?

Pitti: Last April, while Russia was bombing the country, we established a training center in Lviv. This city is close to the Polish border and, thus, in a safe location. That said, Russian forces ended up failing in their attempt to take Kyiv and they amassed in the east and southeast of the country, occupying 20% of Ukrainian territory. In June, July, and August, the fighting — and the victims, predominantly members of the military — were concentrated in the eastern part of the country. We then asked ourselves whether it made sense to keep our training center in Lviv and whether we were still of use when the fighting was limited to the front line and civilians were no longer directly impacted.

Medscape : You moved closer to the front line?

Pitti: Starting at the end of September, the Ukrainian counteroffensive was successful in reclaiming part of the territory. At that time, we thought we’d have to move and go instead toward Kharkiv, [a Ukrainian city located 20 miles from the Russian border], to better meet the training needs of our civilian colleagues. So, although we’d started training in Lviv at the end of August, 2 weeks ago, we left for Kharkiv to offer emergency ultrasound training. It’s led by Dr. Pierre Catoire, an emergency physician and Mehad trainer, and Dr. Vitalii Mahlovayi, a Mehad surgery instructor who was trained in Lviv. Seventeen Ukrainian physicians applied for the training. To make things go more efficiently, we took on only 12 of them — cardiologists, surgeons, emergency physicians, [and] anesthesiologists. These are the caregivers who work directly with the war wounded in the surrounding hospitals. All of them were eager and appreciative of our presence in Ukraine.

Medscape : Why emergency ultrasound?

Pitti: There’s a lot of interest in it, as it enables the staff to complete the clinical assessment at triage. If there are any internal injuries, they can be flagged then. Thanks to ultrasound, you can know whether you’re dealing with pleural effusion, pneumothorax, hemothorax, blood in the abdomen, in the lungs, etc. And because this is happening right there in a clinical setting, if the patient’s condition is critical, surgery can be started immediately. In this respect, ultrasound has become an indispensable tool at triage — and even more so, given how the technology has evolved. Current devices are about 5 inches, weigh around 3 ounces. And you can view the image on your smartphone.

Medscape : Twelve physicians trained in ultrasound. Is that going to be enough to handle the emergency?

Pitti: No. That’s why we went back to Lviv with the physicians who’d just been trained in emergency ultrasound so that they, in turn, could become trainers and return to Kharkiv to train their colleagues. During this mission, we brought two ultrasound machines that could be used around the clock. We left them for the hospitals that needed them.

Medscape : What about treating posttraumatic stress?

Pitti: Last weekend, we offered training on how to treat psychological trauma in an emergency setting. The treatment must start within hours — no more than 48 hours — of the traumatic event. When carried out soon after the trauma, a technique like — Eye Movement Desensitization and Reprocessing (EMDR) — has been shown to be effective in preventing the person from going back into a chronic state. Any physician, psychiatrist or otherwise, or even a psychologist, should be able to offer such treatment. This is why we’ve implemented training in partnership with the University of Lorraine’s Department of Psychology, which is headed by Prof. Cyril Tarquinio and specializes in psychological trauma. It’s a 3-day course, a video conference, with 17 psychiatrists and psychologists working with the Lviv emergency department. We’re now going to move on to the second phase and make sure that some of them, in turn, become trainers so that, eventually, training can be provided by the Ukrainians.

Last weekend, we offered training on how to treat psychological trauma in an emergency setting.

Medscape : What plans do you have for future war medicine training?

Pitti: The next courses will be dedicated, on the one hand, to the treatment of victims of chemical weapons and, on the other hand, to war surgery, damage control war surgery. In addition, we’re going to establish a cooperative relationship between our training center and that of Ukrainian physicians and first aid workers, which lacks pedagogical tools.

Medscape : You were in Kharkiv. What about the hospital there, how it runs?

Pitti: I’ve visited the hospital that was hit by bombs. Part of the children’s hospital is no longer used, by the way. And a lot of physicians and nursing staff left at the same time as the rest of the population. That said, the hospital continues to run, but adjustments have been made to better tackle the situation at hand. For example, the children’s hospital now also takes in adult patients. In the ICU, medical patients and surgical patients are grouped together in the same area. The number of operating rooms went from seven down to three, with two emergency structures. And the ophthalmology department is now used as doctors’ offices, where people go for appointments.

Medscape : And when there’s an alert, what happens — specifically with the pediatric patients?

Pitti: Alerts occur very frequently at the Kharkiv hospital. And it’s too complicated to bring the children in ICU down to the basement every time. When a warning siren goes off, the children are moved into the hallways, far away from exterior walls, and a nurse stays with them. Meanwhile, family members — due to the lack of staff, they’re permitted to help care for the children — they go down to the basement.

Medscape : Generally speaking, what’s current treatment like for the injured and wounded in Ukraine?

Pitti: The Ukrainians are well organized. The hospitals are running — maybe even reorganizing. People injured or wounded on the front line, mostly military personnel, are handled by the country’s military facilities. Those coming from the front are first stabilized at what in military terms are called level 1 facilities, and then they’re sent on to the next level up — level 2 hospitals. The most serious cases — individuals who need to be operated on again to avoid amputations, for example — are evacuated to European countries like Sweden, Norway, Poland, France, and Belgium — within the framework of European agreements.

This article was translated from the Medscape French edition.

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