The War in Ukraine: How Can Emergency Physicians Help?

We have been witnessing a humanitarian emergency of epic proportions in the days since Feb. 24, when Russia launched a large-scale invasion of Ukraine.

The conflict has displaced millions of people and has thrust Ukraine into a global spotlight. The invasion has included documented attacks on Ukraine’s healthcare facilities, including the reported bombing of a hospital’s maternity ward and a children’s clinic in Mariupol. Sadly, even medical personnel — who, under international humanitarian law, are supposed to be protected from hostile action during times of war¹ — have been targeted.

This military activity is taking place in the eastern region of the country, where infrastructure is already devastated because of prior attacks during the ongoing conflict between Russia and Ukraine. A few challenges, from a global health perspective, include limited medical facilities, lack of medical supplies, and obstruction of humanitarian aid organizations that are trying to deliver essential supplies and medications.

Expertise in emergency care is a critical need as this conflict continues and evolves. As emergency physicians, we want to help. And, with some sensitive considerations, we are well-positioned to contribute triage, clinical, and systems management skills during all phases of humanitarian catastrophes. But first, we need to do our homework.

Emergency Medicine in Ukraine: History and Context
The practice of emergency medicine in Ukraine is markedly different from EM in North America. The Ukrainian model of emergency care was heavily influenced by health policies of the former Soviet Union. Key historical differences between U.S. and USSR physician training can be observed in all stages of medical education, beginning with prerequisites for medical school.

To illustrate: In the 1910s, state licensing boards began requiring U.S. medical schools to raise the bar on admission standards and implement stricter curriculum requirements, increasing the exclusivity of the field. In contrast, the Soviet Union issued a resolution of “free and open access to medical education for all” in 1919.^2,3 Furthermore, American physicians had to undergo extensive postgraduate medical training starting in the 1920s, while Soviet physicians experienced the addition of residency training for the first time in the 1970s.^4,5

Ukrainian medical training was influenced and shaped by these types of events. Our emergency physician colleagues in Ukraine attend 6 years of medical school, followed by 18 months of pre-hospital physician training at an emergency medical service (EMS) base station.⁶

Roughly 1,000 residency-trained EMS physicians practiced in Ukraine leading up to the war, with approximately 150 residents currently in training in 12 accredited residency programs.⁷ In Ukraine, EMS physicians operate predominantly in a pre-hospital setting. Ukraine follows a Franco-German model, in which ambulances are usually equipped with basic diagnostic and treatment modalities, one physician, occasionally a paramedic or physician assistant, and one or two nurses. When a person requires immediate medical attention, they call an ambulance instead of going to the emergency department. When the ambulance arrives, a physician evaluates the patient, establishes a preliminary diagnosis, and starts treatment if indicated. Disposition is most often decided in the field, and if the physician thinks the patient requires inpatient care, then the physician arranges for direct hospital admission, bypassing the ED.

This practice has important implications for emergency care. Ukrainian EDs have more in common with American ED triage areas than with the EDs we are familiar with in North America. Patients sit in chairs rather than lie in hospital beds. Imaging and procedures are pursued in inpatient settings rather than in the ED. There is no culture of "going to the emergency department." Instead, patients call ambulances for emergency care. EMS physicians are trained primarily in procedures that can be completed pre-hospital, with limited exposure to cardiac pacing, central venous access, bedside ultrasound, pericardiocentesis, procedural sedation, and lumbar punctures.

Even prior to the current crisis, funding has been the largest challenge for the development of emergency medicine in Ukraine, given the current model of medical financing by the central government — a relic of the Soviet era. Budgets for ambulances, EMS physicians, essential medicines, and medical supplies are limited, leaving emergency clinicians dependent on private corporate donations. Without government financial support, digital angiography suites and cardiac ambulance services are only accessible if local businesses provide financial assistance.

How to Help
Right now, in this time of war, Ukrainian physicians are serving their patients around the clock. There are no shifts or time off. They are always at work, and they are always needed. In times like this, emergency medical knowledge is especially valuable. But even more than that, these brave medical professionals need supplies and financial support.

There are direct and concrete ways we can help Ukrainian physicians on individual and collective levels. Here are a few:

• Donate funds to recognized aid agencies. Many American residency programs organized fundraising events in support of Ukraine over the past weeks. 
• Donate medications and medical supplies. Send medications and  medical supplies directly to Ukrainian hospitals by reaching out to your supply manager. 
• Share your knowledge. Physicians experienced in tactical emergency medicine and in low-resource settings can create and share open access educational content. Content should be evidence-based and easy to access from the To provide the maximum benefit for physicians in war zones, it is essential to first listen to them, and allow them to identify their needs and their available resources. 
• Advocate. Use your authoritative voice as a medical professional to advocate for an end to human rights abuses. For guidance on advocating as a physician, refer to EMRA’s Emergency Medicine Advocacy Handbook, Physicians for Human Rights’ advocacy toolkits and letters, and ACEP’s advocacy guides.

Do No Harm
Historically, well-meaning medical providers have responded to crises with the intention of providing direct care. The presumption is that their training and experience can be readily implemented and produce a beneficial response. The reality is more complex.⁷ A medical degree and residency training are not enough to work effectively in a humanitarian crisis. To be effective, providers need the following:

• Specialized training or experience working in resource-limited or conflict environments
• The support of an established humanitarian organization that has been granted permission by the host country to provide care and has an established logistics package
• The physical and emotional capacity to work in a crisis environment

This applies to attempting to volunteer directly in Ukraine or bordering nations. The reality is that medical personnel who lack experience in resource-limited environments and knowledge of the local culture and healthcare system may generate more work than they accomplish. At worst, they generate the potential for injury or harm to themselves or others around them.

Another common, well-intentioned response is to gather and send medical supplies. The World Health Organization has very clear guidance regarding the medical donation process.⁹ Pharmaceutical and non-pharmaceutical donations generate a substantial logistical burden to transport, store, and safely use. This is expensive and requires its own infrastructure. Governments and the humanitarian sector have established systems and networks to expedite medical aid at the request of host nations. Donating funds to established aid organizations is often more impactful.

All wars end, and this one will end too. In the years to follow, Ukraine will be rebuilt. The recovery phase of disaster is a valuable time for modernization. American emergency physicians can help strengthen EM education and practice in Ukrainian healthcare. North America has specialists in EM education, simulation, administration, and healthcare policy. We can use these valuable skills to aid Ukraine in developing more robust emergency care. It is only by building a robust emergency care system that we can ensure improved disaster response and ensure access to acute care for everyday emergencies.

References

1. Leaning J. Law provides norms that must guide doctors in war and peace. BMJ. 1999;319(7207):393-4.
2. Beck AH. The Flexner report and the standardization of American medical education. JAMA. 2004;291(17):2139-40.
3. Восьмой съезд РКП(б) / Игнатьев В. Л. // Вешин — Газли. — М. : Советская энциклопедия, 1971
4. Ludmerer KM, Johns MM. Reforming graduate medical education. JAMA. 2005;294(9):1083-7.
5. Order of the Minister of Health СССР от 11.11.1971 n 810 " On improving the organization and quality of specialization and improving professional knowledge of medical and pharmaceutical workers with higher education in institutes for the improvement of doctors and other relevant healthcare facilities."
6. Wright SW, Stack LB, McMurray BR, Bolyukh S. Emergency medicine in Ukraine: challenges in the post-Soviet era. Am J Emerg Med. 2000;18(7):828-32.
7. Patino AM, DeVos E, Arbelaez C, et al. 2019 ACEP International Ambassador Country Report Compilation. March 2021.
8. Roberts M. Duffel Bag Medicine. JAMA. 2006;295(13):1491-1492. doi:10.1001/jama.295.13.1491
9. McDonald S, Fabbri A, Parker L, Williams J, Bero L. Medical donations are not always free: an assessment of compliance of medicine and medical device donations with World Health Organization guidelines (2009–2017). Int Health. 2019;11(5):379–402.