October 20, 2023 | Vadim Gudzenko, MD
It had been a year and a half since I last visited my native Ukraine with my family in September 2021. And it had been almost two years since a senseless war erupted after Russia invaded Ukraine in February 2022. It was March 2023, and I was going back home, crossing the Poland-Ukrainian border by train.
This time, a trip that in the past had taken 16-18 hours by plane took me almost two full days, three flight changes, two train connections, and a stayover in a Soviet-style hotel in the Polish border town of Przemysl. The train heading to Ukraine was packed full, primarily with Ukrainian women and children who were returning home from European refuge. A couple of soldiers were returning to service after recovering from their injuries somewhere in Europe. You could see fresh scars on their faces from shrapnel injuries.
This trip started many months ago with a call from my friend and former critical care medicine co-fellow Jose Diaz-Gomez, MD, an internationally renowned expert in point-of-care ultrasound (POCUS). In his typical gregarious way, he asked: "Brother, I was tasked by the Society for Critical Care Medicine (SCCM) president to lead an educational mission to to teach Ukrainian intensivists to perform POCUS. You are the only Ukrainian I know, and I would be grateful if you could come with us. Would you go?" My initial response was not hard to guess—"Absolutely!" From the first days of the war, I was preoccupied with ways to help my country and the people there—sending money to charitable volunteer organizations, organizing fundraising, buying tactical medical supplies for Ukrainian soldiers, and participating in the transfer of medical supplies that UCLA organized. But I always wanted to help and be involved more directly.
Although my immediate reaction was to agree to join the mission, deep down, I was concerned that neither my friend nor the SCCM leadership completely understood the complexity and danger of running an educational mission in a country that was involved in one of the most significant and violent wars of recent times. But I was wrong. This trip became a reality six months later.
Initial POCUS Courses in Lviv
SCCM partnered with the Ukrainian Ministry of Health, the head of the Ukrainian Association of Anesthesiologists, and one of the most modern and advanced hospitals—St. Panteleymon Hospital in Lviv. Lviv, the largest and oldest city in western Ukraine, had become a major transportation hub at the beginning of the war. Lviv became the entry point for all the world leaders traveling to Kyiv, the capital of Ukraine, to meet President Volodymyr Zelensky; for the majority of humanitarian and military supplies coming from the entire world; and for the many volunteer missions that had rushed to Ukraine over the last 18 months. Lviv had also become a transfer hub for several millions of Ukrainian refugees who had escaped the horror of war to Europe.
Our SCCM team consisted of seven physicians and one nurse practitioner practicing critical care medicine, emergency medicine, and anesthesiology in major U.S. institutions. Everyone on the team was an expert in POCUS and an experienced educator. One of our members, Rom Stevens, MD, a retired U.S. Army physician, had extensive experience working in war zones and had already been teaching Ukrainian doctors POCUS and modern approaches to resuscitation and blood transfusion.
When we arrived in Lviv, we were greeted by the leadership of St. Panteleymon's Hospital and shown the space where all the training was supposed to take place—a bomb shelter in the hospital's basement. Most Ukrainian hospitals have bomb shelters capable of protecting citizens from nuclear and chemical warfare—remnants of the Cold War.
After setting everything up, we ran four SCCM POCUS courses—three basic and one advanced—from March 16 to 24, 2023. We trained more than 150 Ukrainian anesthesiologist-intensivists from all regions and a variety of hospitals. In Ukraine, as in the rest of Europe, all intensivists are anesthesiologists. In addition to providing education, we donated more than 70 "Butterfly iQ" portable ultrasound systems that could be attached to an iPad or iPhone and easily used in any setting. Although Ukrainian anesthesiologists have limited experience with echo and POCUS, they routinely use ultrasound for regional anesthesia and central line placement.
My most powerful experience was training a group of military doctors who worked in the stabilization unit next to the front line in Bakhmut. They were sent to take the course and return to the front line with their training. Several days later, one of the doctors sent us a video of how they used the Butterfly to perform an echocardiogram and a focused assessment with sonography for trauma (FAST) exam on a wounded soldier. I had been involved in medical education for more than 15 years; however, I had never seen such quick and impactful results of my teaching before. It became clear that we were teaching vital skills that would immediately save lives.
Another powerful experience was witnessing two colliding realities that Ukrainians live out daily—trying to continue normal life under the constant threat of deadly attacks. From the outside, life goes on without interruption—the streets in Lviv are full of people, public transportation runs like a clock, and restaurants and coffee shops are packed. At the same time, you can see many uniformed soldiers coming for vacation from the front lines, hear not-infrequent air sirens, and encounter many amputees, both military and civilian. I asked one of the Ukrainian doctors how they could reconcile these two realities. She answered that this is the way to show resilience. The Ukrainians had cried in fear and anguish for the first two months of the war, but that was enough. They needed to continue living their lives; they needed to run an economy and prepare for life and the rebuilding of their country after victory.
Upon completing the course, we felt that we needed to continue our work and plan for the next visit..
“Train-the-trainer” Courses in Kyiv
Six months later, in September of 2023, we had the opportunity to return with the SCCM team and repeat two advanced POCUS training courses. However, I felt this U.S.-driven approach would not produce long-term, sustainable results. With Aliaksei Poustovaitou, MD, from Johns Hopkins University, a co-founder of the SCCM POCUS course, we concluded that we must train Ukrainian specialists to become POCUS instructors. After several Zoom meetings with Ukrainian doctors and with the support of the head of the Ukrainian Anesthesiologists Association, we created our plan. We identified 12 of our former students to become instructors for the basic SCCM courses who would give lectures and provide all hands-on training according to SCCM standards. Dr. Poustovaitou and I planned to serve as mentors and moderators for the course.
This time, we arrived in the Kyiv by overnight train from Lviv. As we walked around the city early on a Sunday morning, we were stunned by the incredible beauty of the city. Kyiv strikes you as a vibrant capital with wide streets, modern architecture, car traffic, and crowds of people spending their weekend mornings in the parks. Numerous coffee shops are on every corner. But Kyiv also has an ancient and complex history. It was established by Viking nobility over a thousand years ago as a center of what later became the Kyivan Rus, the cultural ancestor of the nations of Belarus, Russia, and Ukraine. Later, Kyiv became the place where the Byzantine Empire introduced Orthodox Christianity to the region. Ancient churches and monasteries with golden domes and roofs remind visitors of the city’s rich history.
As we walked the streets of Kyiv and enjoyed sightseeing in this progressive city, I wanted to be in my usual careless travel mode. But this was impossible. Signs that the country was in a state of brutal war were everywhere. Large numbers of soldiers on the street, memorials to recently fallen soldiers on the main square (Maydan), and an exhibition of destroyed Russian tanks that had almost made it to Kyiv in February 2022 were constant reminders.
We were greeted by Professor Dubrov, Deputy Minister of Health and Head of the Ukrainian Association of Anesthesiology. We talked about living amid constant bombing threats and uncertainty about the future. He reflected on the first days of the war, when he spent eight days in a row caring for numerous civilian trauma patients. When he finally left the hospital, he couldn't believe the apocalyptic picture that he saw—empty streets, burned cars, and damaged buildings in a city that was full of life just one week ago. Now, Kyiv has partially recovered from the early horrors of the war. Still, air sirens and air attack notifications on mobile phones constantly reminded us that the threat of deadly attack is a part of everyday life.
We also discussed with Professor Dubrov the current state of Ukrainian healthcare. Numerous problems are deeply rooted in the archaic soviet model that still exists. While business practices, information technologies, and the hospitality industry in Ukraine are fairly advanced, other social services like education and healthcare have largely remained stagnant over the last 30 years. Technically, healthcare is universal, and the government is supposed to pay for everything. Still, it doesn't have enough resources to do so. And the private insurance sector is underdeveloped. As a result, patients end up paying for most of their care out of pocket, creating an environment of corruption and inequality.
The next day, we started POCUS "train-the-trainer" program. We ran two 2-day courses for Ukrainian doctors in Kyiv. Our former trainees ran the sessions with very little involvement from us. It was an incredible experience to see our former students running complex courses and teaching other doctors. We immediately realized that their impact would be much more widespread. First, they could instinctively relate to regional medical problems, which naturally placed all education in a more meaningful clinical context. Second, conducting the training in the Ukrainian language helped them deliver significantly more content than we could with previous translations.
Although most of them had no prior experience in teaching, they adjusted with exceptional speed, incorporating our minor suggestions and finishing all courses on a high note. It was also exciting to see the traditional model of Ukrainian medical education upended during this time. Medical training in Ukraine is based on an old-fashioned hierarchy in which senior physicians, chiefs of service, directors, and chairs—considered to be the sources of ultimate knowledge and experience—cannot be questioned or challenged. As a result, junior attendings are supposed to follow their seniors without questioning and are frequently dismissed and undermined. It is highly unusual for a junior attending to serve as an educator or "boundary pusher." What happened in Kyiv during these four days was extraordinary. Twelve junior attendings in their late 20s or early 30s taught more than forty doctors, many of whom were substantially older, including several chiefs of service and department chairs.
Despite declining mass media coverage, the war in Ukraine remains active. Numerous military casualties are reported from both sides every day. Ukrainian cities are bombarded regularly, bringing destruction and death. But the resolve of the Ukrainian people is undeniable. War became part of life, but life continues. As the Ukrainians survived a brutal winter with their electrical grid being systematically hit by Russian rockets, they reflected on the constant electrical blackouts with smiles on their faces. They recalled how they adjusted by buying electrical generators, camping stoves, and sleeping bags, restructuring their daily life around several hours of electrical power per day. They are also guessing how this winter will be—better or worse. As Russia is preparing stockpiles of rockets, and Ukrainians are looking for a way to diversify the power delivery and distribution in the country, the upcoming winter will be another test of Ukrainian resolve and grit. But one thing is clear—Ukrainians will never give up or accept anything but complete victory.