Following the 2022 Russian invasion of Ukraine, I was asked by a nongovernmental organization to teach a modified version of Advanced Trauma Life Support (ATLS) to Ukrainian physicians. Developed and supervised by the American College of Surgeons (ACS), ATLS provides a standardized system for evaluating and treating trauma victims.
Teams of Western-based instructors began teaching the two-day ATLS course in August 2022. Travel and logistics were handled by the International Medical Corps and the Harvard Humanitarian Initiative. Interestingly, the first team of instructors was composed almost entirely of individuals with prior military experience. This turned out to be a good decision, as later teams had at least one member with no prior military experience who abruptly departed for home after being in range of some blasts. In between ATLS sessions we also taught Stop the Bleed, another ACS course, to non-physicians such as schoolteachers, librarians, and bus drivers.
ATLS slides were translated into Ukrainian and double-checked by our interpreters for accuracy. A professional interpreter was with each American instructor at all lectures and hands-on skill stations. Training videos were subtitled, and lectures were accompanied by simultaneous interpretation/explanation. The long-term goal was to build ATLS instructional capacity within the country by training Ukrainian instructors. Thus, the U.S. instructors assessed each student group for candidates with potential as future national instructors.
Ultimately, we were able to step back, provide teaching training, and observe Ukrainian instructor candidates teach, which they did exceptionally well. The final U.S.-led instructor teams teaching in Ismail, Odesa, and Vinnytsia certified the Ukrainian instructors we had selected. In all, we trained more than 1,000 physicians in ATLS in 22 waves. Several individuals had tears in their eyes when presented with their instructor certificates—they told me they had been trying to get ATLS taught in Ukraine since 2014, but until the 2022 invasion there was no buy-in from ACS. Now they are on their way to running the program themselves.
We taught, but we also learned a lot. The Ukrainian medical system is very different from that in the United States. The Soviet-style hierarchy persists in that the Ukrainian healthcare system appears somewhat authoritarian and protocol driven. The Ukrainian Ministries of Health and Defense publish clinical practice guidelines that seem to be treated as directives to be followed without deviation. Lecture time was lost to arguments that started, “But our protocol says. . .”.
Residency training is shorter than in the United States for many programs, and certain specialties are very constrained by the budget. And as one might expect, training and many educational opportunities have been heavily affected by the war, and postgraduate medical education is very limited by Western standards and there are few advanced fellowship opportunities.
Ukrainian health care is underfunded (7 percent of GDP prewar compared with 10–11 percent in the EU and 18+ percent in the United States), and physician and nurse salaries are low. Resident doctors often hold second jobs and live with their parents to save money. Inadequate salaries encourage the persistence of “unofficial reimbursements.” Years of Soviet rule inculcated a mentality that patients and families must provide some form of reimbursement to the treating doctor to ensure good professional services.
Adopting a Western-style healthcare system in the immediate future is not a reasonable expectation for Ukraine, as limited national resources are now even more severely stretched by war. Healthcare reform has taken a back seat to the fight for national survival.
The Ukrainian people have rallied and developed a solid identity in the defense of their nation. They are educated, tech savvy, and seek partnership with the West. Many younger students have studied the English language and are familiar with Western culture. To help Ukraine defend democracy and modernize its health care, long-term commitments by allied nations and charities and partnerships with specific Ukrainian hospitals are needed. International education along with military support is an act of solidarity. They will never give up.
Slava Ukraini.
