Neurosurgical Mission to Ukraine

Abstract

Ukrainian health care before 2021 was like that in comparable middle-income countries. The conflict with Russia over the last 8 months has added significant burden to the already resource-constrained system. We describe the current neurosurgical situation in Ukraine as well as remote and in-person efforts to provide needed assistance to Ukrainian neurosurgical colleagues.

Recently, multiple medical missions have been deployed to offer support for Ukraine's acute care and trauma systems, strained due to the ongoing conflict. This has been at the request of the Ukrainian Ministry of Health and supported by the nongovernmental organization Global Surgical and Medical Support Group. The missions have been multispecialty in scope but primarily focused on services related to acute care and trauma care. Typically, 4 US health care providers have spent 2-week rotations in several major hospitals throughout the country. Specialists have included trauma surgeons, burn specialists, orthopedic surgeons, and trauma nurses. Neurosurgery was represented on a recent mission and aspects and observations of the current neurosurgical situation in Ukraine will be the focus of this review.

Currently, Ukrainian neurosurgery is segmented into a significant military component (including several civilian neurosurgeons who have joined the war effort) and a civilian system. The prewar state of neurosurgery was similar to that found in many middle-income countries. Recent data suggest that overall neurosurgeon density in Ukraine is comparable with European countries; however capacity does not cover overall demand.¹ The foundation for Ukrainian neurosurgery and neurosurgical training is Soviet-based and established before Ukraine's independence in 1991. Hospital infrastructure is generally old and, at most institutions save for quaternary referral centers in Kyiv, the availability of modern technology is limited (Figures 1 and 2; note: The participants and any identifiable individuals consented to the publication of their images). Military hospitals in the western part of the country seem slightly better resourced and serve as the second or third tier stops for wounded soldiers and civilian casualties. There is an active patient transfer program between these hospitals and several centers in Western Europe. At most military and civilian hospitals encountered, there is limited access to MRI imaging, intraoperative technology such as power drills, cavitron ultrasonic surgical aspirator, navigation systems, and modern neurosurgical microscopes as well as common disposable items such as scalp clips, hemostatic agents, cottonoids, dural substitutes, and biologics.

FIGURE 1.: Neurosurgical operating suite, Cherkasy Hospital 3, Cherkasy, Ukraine.

FIGURE 2.: Craniotomy tray, Cherkasy Hospital 3, Cherkasy, Ukraine.

The flow of acutely injured combat neurosurgical patients is affected by the realities of the tactical situation on the ground and in the air. In Iraq and Afghanistan, coalition forces relied heavily on air evacuation to higher levels of care that provided neurosurgical treatment. In Ukraine, there is very limited ability to rapidly evacuate casualties by helicopter. This has necessitated the deployment of acute care neurosurgeons to forward line field hospitals where initial damage control procedures are performed. Once these patients are stabilized, they are transferred to either military or civilian hospitals further west from the front by nighttime trains. These trains arrive in cities such as Kyiv, Dnipro, and Cherkasy every few days carrying 50 to 100 patients of varying injury severity and stages of care. The flow of patients continues from these “midway” cities westward to Kyiv and Lviv and then perhaps Western Europe, dictated by capacity issues and need for complex care.

Frontline hospitals are manned by the military and remained inaccessible to the support mission. While we were able to connect with military neurosurgeons at the front and send them supplies from Lviv, our direct interactions were in the cities of Lviv and Cherkasy.

Our mission aim was multifaceted. Through prior missions that did not include neurosurgeons, we were able to connect virtually several months before departure with both Ukrainian military and civilian neurosurgeons. This allowed for assessment of acute supply and equipment needs that could be distributed during the trip, with enough time to seek grants from companies and health care institutions to meet some of these specific needs. There is currently no modality by which to ship from the United States directly to Ukraine reliably, so requests were honed to smaller items that could be checked in baggage on the transatlantic flight to eastern Poland and transported with us by van across the Poland-Ukraine border (Figure 3). Items carried and requested for donation had a wide range: head fixation devices, micro instruments, bipolars, dural sealant and allograft, hemostatic agents, scalp clips, and an extensive assortment of endovascular supplies. These were distributed based on specific need either directly in person or via Ukraine's internal shipping service to neurosurgeons at the front. On a prior mission, several planning CT scans were loaded on a flash drive and brought to the United States where custom polyetheretherketone cranioplasty implants were manufactured and brought for implantation on patients at the Lviv adult and pediatric hospitals.

FIGURE 3.: Donated neurosurgical supplies in route to Ukraine.

The mission engaged in educational efforts, both didactic and on a less formal basis. Global Surgical and Medical Support Group has been training Ukrainian surgeons, physicians, and combat medics on the ground since 5 days after the start of the war. As missions later began to include physician subspecialists, most of whom have prior military experience, a series of lectures ensued focused on surgical and critical care of trauma patients. These were delivered in grand rounds formats at both the hospitals in Lviv and Cherkasy (Figure 4). Remote virtual lectures have also been incorporated as part of the educational efforts. A regular remote lecture series is now being led by the chief surgeon at the Kyiv Military Medical Academy. Neurosurgical lectures were developed to address current interests and also be consistent with the reality of resource limitations. Teaching rounds were carried out with attendings, residents, and medical students daily through critical care units and operative cases were reviewed and discussed collaboratively.

FIGURE 4.: Neurotrauma grand rounds, Cherkasy Hospital 3, Cherkasy, Ukraine.

In Ukraine, medical education is a 6-year program that begins after secondary school. The path to become a neurosurgeon typically follows with 3 years of surgical training followed by a 10-month course in neurosurgery. At this point, training is considered complete and one is deemed an adult neurosurgeon. Pediatric neurosurgery training is a separate program after general surgery. Residents typically pay a monthly fee for their training. There is a long period spent as a “junior attending” at most institutions before new neurosurgeons are capable and able to function independently. Neurosurgical salaries are $500 to $800 monthly and supplemented by a “patient gratuity” system. On multiple occasions, junior neurosurgeons expressed frustration that the current system does not incentivize mentorship and teaching. Our missions often found young, eager surgeons interested in collaborating, while Soviet era colleagues seemed less receptive to interaction and exchange of ideas (Figure 5).

FIGURE 5.: Neurosurgery department personnel, Cherkasy Hospital 3, Cherkasy, Ukraine.

In addition to supplies and education, prior missions have engaged in direct patient care, both consultative as well as operating and assisting on surgical cases. With the establishment of direct relationships between Ukrainian neurosurgeons and American colleagues, specific case consultations through remote telehealth platforms have also been ongoing. As mentioned, damage control surgery is performed at frontline military facilities, so trauma, burn, orthopedic, and neurosurgery cases at hospitals further west did not typically involve acute war injuries. From the neurosurgery standpoint, these cases most often involved cranial reconstruction, endovascular therapies, exploration and grafting for traumatic peripheral nerve injury, and spinal trauma (Figure 6). The surgical experience was very different from that found in neurosurgical operating rooms in the United States. These differences ranged from procedural (lack of presurgical timeouts/checklists) to antibiotic prophylaxis (typically continued for many days) to technological (lack of modern neurosurgical microscope or powered drills). Surgeon skills with the tools available were often impressive to witness.

FIGURE 6.: Custom polyetheretherketone cranioplasty implantation on a 12-year-old war casualty, Saint Nicholas Children’s Hospital, Lviv, Ukraine.

It would be presumptuous to believe that on a time-limited mission we can have full understanding and insight into the current challenges faced by our Ukrainian colleagues. The neurosurgical support resulted in the establishment of excellent connections between many Ukrainian neurosurgeons and US counterparts (Figure 7). This was both through direct engagement and, in some circumstances, virtual connections to those on the frontlines. Going forward, we believe that these connections are what can facilitate ongoing support and improvement in conditions. It is extremely challenging to remotely assess and understand what might substantially help this difficult situation. The neurosurgeons in Ukraine are best suited to guide us toward providing the most effective international support and outreach, as they strive to better care for their patients. Too often, we would witness donated pieces of technology in the operating rooms either unused or unusable because of lack of ability to service or maintain a flow of disposable parts. Apart from missions such as that described above, our impression is that facilitating young Ukrainian neurosurgeons' ability to experience periods of “observer ships” at established neurosurgery programs throughout the world will allow them to understand fully the spectrum of what is available to practitioners and return to Ukraine in a better position to begin to implement incremental and sustainable improvements that can result in meaningful long-term change. We advocate for organized neurosurgical societies globally to actively and aggressively support these sorts of programs both financially and with a commitment to teaching. Ultimately, while medical missions abroad such as what we participated in can have significant impact, true change will, by necessity, come from those Ukrainian neurosurgeons committed to making it happen.

FIGURE 7.: Dr Sheinberg and Dr Lovha, Lviv, Ukraine.