I had been thinking of going further into the country and doing “the actual work” for quite some time now. After a few months of gathering intelligence, and thinking about the best use of my time, I finally settled on a tertiary centre in the capital, which has been admitting the wounded since the beginning of the war. Through my previous work in Kyiv, I have got a few contacts who had helped me get in touch with the right people there, and off I went to Poland in my car, and then by train into Kyiv. I decided to drive as I did have some supplies to take with me from the UK, and also a few boxes of tactical medical stuff, which were donated by a German Rotary Club through a Ukrainian friend of mine working there. I handed all the boxes to the volunteers I work with in Krakow, and took a train to Kyiv from Przemysl, a pretty historic town close to the Ukrainian border.

I did not have a detailed plan of what I was going to do there. I knew that they were trying to run elective specialist programmes, including Thoracics and Liver surgery, which I have some experience with through my work here at the UK. I also had a fairly good understanding of what the Ukrainian healthcare had been like before the war, and what was generally lacking in addition to equipment, and disposables.

Their work is split between caring for the wounded, and specialist elective surgery, including liver transplants, and cardiac surgery! The split is about 70/30 in favour of the wounded, but they took a week off and decided to stop admitting the soldiers to catch up with the elective stuff, use my presence to the max, and also clean the hospital. And that brings us to their main problem – the prevalence of in-hospital infections. They are not a field hospital admitting the wounded directly from the frontlines – they are a long way away from where the actual fighting takes place. The soldiers go through a few medical facilities before reaching their hospital, picking up various bugs along the way, which also become resistant as there is often very basic to no infection control in most of those places. Basically, a patient gets whatever a hospital gets with a humanitarian aid shipment at the time. If they have Meropenem, then that is their first-line empirical treatment/prophylaxis! By the time they reach the Kyiv hospital, they all have multi-resistant Klebsiella, and Pseudomonas in their big open wounds, and if they still don’t, then they get them from their next-door neighbours on the wards. It is the main challenge – to not only treat the multi-resistant inhospital infections, and limit their spread among the wounded, but also to keep elective patients “clean” throughout their journey. This is the area which need an urgent overhaul, and an introduction of a systemic change. As it stands, infection control as a system does not exist.

One of the life-changing injuries they have dealt with.

A horrendous, life-changing injuries that the guys have to deal with daily.

More horrors…

Consequences of cassette bomb use.

War is hell…

A captivating image from a Dutch newspaper of one of soldiers treated in the clinic.

It is, therefore quite amazing that those guys are managing to do some impressive elective work done. They try to keep patients separated both on the wards, and in their operating theatres. Luckily, they have two dedicated theatres on the ground floor, and they never take infected patients there keeping them reserved for “clean” work only. They booked a fair amount of elective Thoracic cases, some of them quite challenging even by our standards on the week when I was there, which I was able to get involved in, and help them with. There were also a few soldiers with Thoracic injuries, who needed sorting out. It was also good just to help them with endless washouts and debridements, and give the guys and girls a break. They have basically been living in the hospital, literally with their families during the first two months of the war, and doing long hours with few days off therafter. 

Doing lung transplant (first ever in Ukraine!) in one of the “clean” theatres.

In addition to the theatre-based hands-on training, they had set up a few “masterclasses” on airway management, and major blood loss for Anaesthetic trainees based in Kyiv. They were attended by 100+ juniors, and very well received, and appreciated. However, I felt that my main focus, and impact was on everyday running of theatres. It was an introduction of general safety measures, checklists etc – anticipation, and prevention of potential problems, rather than putting down fires that would hopefully make the biggest long-standinng impact on their work. It was my working side-by-side with my Ukrainian colleagues, as well as frank discussions around the table at the common room, which they found the most valuable outcome of my visit. Little subtleties, “have you thought of doing it this way” questions, which hopefully helped them re-assess a few well-established, but at times outdated practices. Overall, I was impressed by their levels of clinical competence, and even picked up a few things that I would like to introduce into my practice here in the UK.

At a masterclass on difficult airway.

With the trainees and the faculty.

…and then I got to manage a difficult airway in theatre after lecturing on it!

The majority of doctors, and all of the nurses are of the same age as the soldiers that they treat. Seeing those horrendous injuries day in, and day out has undoubtedly taken its toll on them. Also, there is not a single one of them that has not lost a member of their family in the past year. Yet, I have not heard a single complaint, or even the slightest hint of feeling sorry for themselves during my stay with them. It was quite clear to me that they had gotten very close, and looked after each other very well. Nobody  there is in a uniquely desperate position; they all share the same pain, having to deal with similar losses, and cannot really claim any particular “victimhood” that would make them qualify for some extra privileges. They do what they have to do, and they try and look after each other in the best way that their circumstances allow, and that was very humbling for me to observe.

In theatre with my hosts.

There is a box on the table at the Anaesthetic common room filled with antidepressants, and antipsychotic drugs for “emergencies”.

“Emergency” drugs.

At a Georgian restaurant. The best drug is having great people around you when the going gets tough!

The hospital is situated on the southern outskirts of the city. When the war started, it was the only road out of the city that was not cut off by Russians. They told me that inspite of the common narrative, no strong leadership, or in fact the rule of law was felt on the streets of Kyiv in the first three days of the war. Citizens self-organized, and started patrolling the streets showing their will to defend the city. Many Ukrainians returned from abroad, including a few with a combat experience, having fought in the East in 2014. In fact, I have met one of them there, previously an Anaesthetic Consultant colleague from a hospital not far from us here in the south of England, who went back to defend his country on day three of the war. He told me about his crossing of the Polish-Ukrainian border – there was a 40-kilometre queque consisting of women and children on the Ukrainian side of the border heading to Poland, and a not-as-long, but long enough queque of men in military fatigues on the Polish side of the border, going home to fight for their homeland. He said that he physically felt the irreversability of his decision as he crossed  the white line, separating the two countries. He has been in the trenches for the whole year, and I feel like I do not need to watch “All is quiet on the Western front” after spending a couple of hours talking to him…

Anyway, after the people had shown their willingness to fight, their Government decided to step in, and lead them on. Guns were handed over to those willing to join the territorial defence, and many joined queques to get an AK rifle. Many Russian saboteur units were active in the city in the beginning of the invasion. In fact, there was a group in an ambulance, which tried to break into the hospital, but was stopped by the Ukrainian soldiers whose unit was stationed on the hospital’s grounds. All the casualities that the hospital was admitting during those early days were victims of “friendly fire” – basically people with guns, who have had little training, but experiencing high levels of anxiety, and very low threshold for pulling the trigger. One of the first casualities was a teenager, who was travelling in a car with his family, who had managed to escape from an occupied town not far from Kyiv. They travelled at night, and did not see the checkpoint upon entering the city… No warning shots were fired. None of them survived…

For two months, all the hospital staff were living on the hospital grounds with their families. During air raids, and rocket attacks, they would go down into the “atomic bomb shelter” built during Soviet times. The hospital had uninterrupted food supplies, which helped them survive as there were only Snickers bars in the shops at the time. Many men sent their families to the West, but the majority  of them have now returned back to Kyiv. There was no active fighting near where they were, but they could hear, and feel Russian artillery shelling in nearby towns in the first couple of weeks before they were forced to withdraw from Kyiv.

Kyiv now looks beautiful. It is actually quite strange to see some sort of normality, at least on the outside. There is a curfew, and it is still being bombed with rockets (in fact, there was allegedely the largest-scale rocket attack when I was there, which I successfully overslept), but otherwise it is open for business with restaurants, bars, theatres and museums running as per their normal schedule. The only difference is that shows are interrupted, and the viewers are directed into a closest bomb shelter if air raid sirens go off. I spent all week in theatres, but on my last day had a tour of the city kindly organised by one of the theatre HCAs, a former history teacher, and a professional tour guide with a great love for the city. It was a beautiful sunny day, and paradoxically a great time to see all the old monasteries in the centre, with no crowds of tourists quequing up to see them. Having spent a week in a fairly bleak place, it felt strange being a tourist, and enjoying the views that all those poor soldiers in the hospital were not able to see, maybe ever. But, that contrast made me appreciate my freedom, and the beautiful sunny day even more than I would have otherwise.

One of the prettiest churches in Kyiv with a crooked cobbled street running down the hill.

Saint Sophia

Inside one of the old monasteries.

Russian scrap metal on display on a central square.

A view on the Dnipro river from one of the hills.

A view of the Maidan square.

There was a poignant episode when we visited one of the old churches with an older anaesthetist called Oleksandr, who volunteered to take us around in his car. It looked stunning with its golden domes reflecting the bright afternoon sun. Oleksandr said casually – “My son had a military funeral in this church a few days ago. He had been with a special ops unit, and had been killed in action while on a mission inside Russia. I have another son, who is at the frontline now”. There was no mention of this either before, or after that conversation. Those people are truly made of steel…

With Oleksandr and our guide in front of St Michael, the protector of Kyiv.

The church where Oleksandr’s son was sent off.

As you could see, I have gotten quite close to the guys I have spent a week with. Since coming back home, I have not stopped thinking about how I could best help them. I would love for them to come and spent a couple of weeks with us here (not all of them at once, of course), so that they could introduce, and adapt some of our safety protocols, and procedures into their environment. It is hard to explain those things in theory. The biggest barrier for them now is getting a permit to leave the country, as all men of a draft age are not allowed out of the country, and the mobilization laws are being tightened due to the heavy losses in the East. The other barrier for them is the cost of clinical attachments, which for most is quite prohibitive. Along with my colleagues, we will try to make it happen once the situation with leave permits is resolved.