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Emergency physician Daniel Schnorr has helped to evacuate patients away from the fighting in Ukraine via medevac train.

Q&A: As a doctor in a warzone “you have to come to grips with your limitations”

When roads become dangerous and it’s no longer safe to fly, it’s time to turn to the train tracks. In Ukraine, health workers have retrofitted a passenger train to evacuate patients away from hospitals near conflict zones.

It’s one of several initiatives Médecins Sans Frontières (MSF) has launched in Ukraine since Russia invaded the country in February. MSF staff have been preparing hospitals for mass casualty situations, delivering emergency supplies, and training local doctors in battlefield medicine – from extracting bullets and shrapnel to wound cleaning.

Canadian-American emergency physician Dan Schnorr is one of the healthcare workers involved in the medevac train project. CMAJ reached him in Dnipro.

CMAJ: How has the situation in Ukraine been evolving?

We entered Ukraine on about day 10 of the invasion… It was just so much unknown, the lines weren’t drawn yet, and it was all moving so quickly. Now, we understand a little bit more where we can go and where we can’t. It remains a huge challenge to get into the areas where there is fighting. A lot of what we’re doing is preparing hospitals that are now in a place of relative safety for if the frontlines get moved and they become overwhelmed. Now is the time to prepare because later on, it might not be possible.

CMAJ: Tell me about your work.   

We entered with a surgical team – an emergency doctor (that’s me), a surgeon, an anesthetist, an operating theatre nurse, a polyvalent nurse, and a logistician. We had a risk kit with us, which is basically all you need to perform five surgeries per day for a week. You can set up an entire operating room with it. But we soon found out there wasn’t a need for that. Surgeons are one thing they definitely have here!

The first place we went was Kyiv and we worked at the largest children’s hospital in the country. They’d been able to evacuate a majority of their patients – a lot of the population, in general, had left Kyiv – so they converted their ground floor into a trauma center to take care of war-wounded adults and children.

We helped the hospital staff develop a mass casualty plan for how they would react if their resources became overwhelmed. At the same time, our surgeon trained staff on war injuries. They have a lot of good surgeons but blast injuries and high-velocity gunshot wounds are not normal gunshot wounds.

Then we moved toward the east where fighting has been intensive. We’re in Dnipro now, at the main accepting referral hospital for the whole East of the country. We’re working with some of the hospitals here doing mass casualty planning again, and we’re building an emergency room in the basement of one of those hospitals. They have a bunker that’s like a Soviet-era hospital.

We also retrofitted a passenger sleeping train into a medevac train to evacuate patients from hospitals that are under stress to areas of relative calm.

CMAJ: Why are trains needed for medical evacuations?

It’s logistically very challenging to move anyone in the country. The trains have been an incredible lifeline. Obviously, there’s no flying anywhere anymore. You can evacuate a patient in an ambulance, but that’s one patient at a time. Plus, it’s bumpier and less comfortable, so there’s a limitation in the types of patients you can take. But with a train, we can take up to 56 patients at a time. We can’t take ventilated patients, but we can take almost anyone else. We hope to have a train that’s a level three intensive care unit soon.

CMAJ: What is the biggest need right now?

What patients and doctors need is protection. They need guarantees from both sides that medical facilities will remain sacred places that will not be hit.

People talk about humanitarian corridors, but humanitarian corridors are a last resort. We believe that patients, wherever they are, should be protected. If they choose to leave, they should be granted safe passage at all times, not at a predefined time or place, as implied by a humanitarian corridor.

Medical providers should also feel safe in their hospitals. They should feel safe going to and from their house to the hospital. That’s what they want more than anything.

CMAJ: Was there anything that you didn’t feel adequately prepared or trained for?

I had to come up with a plan for a chemical, biological, radiological, or nuclear explosion attack for my entire team and help hospitals to develop their own plans for if that happened near them. But I’ve never had any personal experience with that. I just had the theoretical background.

I also had to train our team on how to put on the chemical PPE. I’ve never had to use it before so I was learning as I was teaching others.

CMAJ: How has your time in Ukraine impacted you?

I don’t take safety for granted. And I’m inspired by the doctors and people of Ukraine. As Doctors Without Borders, we choose to go to war zones. Ukrainians didn’t choose this. They’re just normal people living their life and all of a sudden, this war came to them. Normal people step up and do amazing things when they’re challenged.

At one point, we were in Zaporizhzhia – that’s where people who were getting out of Mariupol escaped to. We went to four hospitals and evaluated patients who were injured in Mariupol or while leaving that area. They had very severe injuries, including pediatric patients. People had disfiguring face wounds and everyone had severe psychological damage. They were just shattered. That stood out to me… seeing very grievous injuries that were sustained by civilians. It’s going to take a long time to recover psychologically.

CMAJ: How do you cope with that and protect your wellbeing?

If you can identify a patient that you can help, then that helps. When we were finally able to get the first nine patients on board [the medevac train] – it’s not like nine patients is a ton of patients – but it was like, we’re actually delivering a concrete benefit.

There was a temptation when I was first entering the field to think “I’m gonna save lives and save the day.” When you go into a situation with that mindset, you’re immediately humbled. You have to be able to work with other people providing other types of services, with hospitals that are already there, and listen to them and understand what they need.

This is a huge war and I’m just one person and we’re just one organization. We can’t face down a military group. If we were to take unnecessary risks, like trying to enter a place that’s under bombardment, we could be contributing to the problem and become patients ourselves.

Part of it is being thoughtful about how you can help and understanding your limitations. Doctors particularly struggle with this.

CMAJ: It sounds like there were times you weren’t able to provide the care that you wished you could, especially when you weren’t able to go to certain places.

That was really frustrating. We knew what was going on in Mariupol [a besieged coastal city that endured heavy shelling], but we couldn’t go. Mariupol is the prime example but there are other places, too.

When we were in Kyiv, we knew that we couldn’t get to places near the frontlines, like Irpin and Bucha. And of course, now look at what’s happened in Bucha [where the bodies of hundreds of civilians were found after Russian troops pulled out] and all the atrocities that have been unveiled.

When you go to hospitals and they’re coping fine, you know that others aren’t but we can’t access them. A lot of people struggled with that, including me.

CMAJ: Is there anything that you’ll take away from your experience that will impact your North American practice?

I hope I don’t see blast injuries anytime soon [in North America]. But if I did, I’d be a little bit more prepared to care for them.

Editor’s note: This interview has been edited for length and clarity. Photo courtesy of MSF.

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