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SCCM Pod-500: Bedside in a Battle Zone: SCCM Sends Help and Hope to Ukraine

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SCCM volunteers traveled twice to Lviv, Ukraine, in 2023 to train nearly 500 clinicians on lifesaving education focused on point-of-care ultrasound (POCUS), Fundamental Critical Care Support: Surgical, and ICU Liberation. In this very special 500th episode of the SCCM Podcast, these volunteer faculty share insights into their inspiring and educational mission.

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Dr. Enfield: Hello, and welcome to the Society of Critical Care Medicine Podcast. I’m your host, Kyle Enfield. Today, I’m joined by Dr. José Díaz-Gómez, MD, FASE, FCCM, and Dr. Aliaksei Pustavoitau, MD, MHS, FCCM, to discuss SCCM’s recent mission to Ukraine. Dr. Díaz-Gómez is chief of the Cardiothoracic, Mechanical Circulatory Support and Transplant Critical Care Section at the Texas Heart Institute at Baylor St. Luke’s Medical Center and director of critical care echocardiography. He also serves as program director of critical care medicine at Baylor College of Medicine and was the SCCM Ukraine mission leader.

Dr. Pustavoitau is an associate professor of anesthesiology and critical care medicine at Johns Hopkins University of Medicine. He serves in many capacities, including director of echocardiography and medical director of adult respiratory care services. He disclosed, prior to this recording, that he has an equity ownership in CoapTech and stock ownership in GE Health, Butterfly Network, Moderna, Pfizer, AstraZeneca, Atea Pharmaceuticals, and Sana Biotechnology. Welcome to you both. Thank you for taking the time to sit down with me today. Dr. Díaz-Gómez, do you have any disclosures?

Dr. Díaz-Gómez: No, I don’t have any disclosures.

Dr. Enfield: I know you guys were both deeply involved in this mission to Ukraine. I wonder, Dr. Díaz-Gómez, if you could just give us some background on how this mission evolved and what its purpose was.

Dr. Díaz-Gómez: Thank you. The way it evolved was with a phone call from our SCCM CEO. He was very clear on the purpose of the mission, to provide fundamental knowledge and essential skills in critical care ultrasonography to Ukrainian physicians and medics. That was the first offer, and I needed some time to really think about such a unique mission I never have done in my life.

Dr. Enfield: When you were thinking about that kind of mission, what are the thoughts that went through your mind, and how did you plan for it?

Dr. Díaz-Gómez: First of all, I thought that the Society has put so much investment over the last decade into education in this field involving probably over a hundred physicians and advanced practice providers. So I knew the quality of the program was really good, but then how to translate that educational intervention in a war zone in a different language and with the faculty we can recruit, we can bring together, who probably I haven’t worked with in the past, it was the very first step. How would I envision that? That was my first step, trying to really envision what we have in the United States, how we can do this. Pretty much, he told me, we need to develop this in less than six months.

Dr. Enfield: That’s a pretty short turnaround to develop an entire program in a different language, so I’m impressed that you all were able to get that done. I wonder, Dr. Pustavoitau, what got you involved, and how did you decide to join this mission?

Dr. Pustavoitau: My pathway was somewhat different. Ever since the start of the current invasion by Russia into Ukraine, I was interested in actually helping the Ukrainians to achieve greater response from the medical side. Starting in March of 2022, we were actually sending some ultrasound devices into the country, and I had several of my friends and acquaintances on the ground in Ukraine who were doing some teaching already in the country. I was part of the adult critical ultrasound faculty. During the August summer courses in Chicago, I actually brought this up also with the SCCM leadership, at which point, the CEO mentioned, “Hey, that’s what we are putting together. Would you consider also joining that?” So I joined. In the meanwhile, the Ukrainian leaders in anesthesiology and critical care, which is actually the same specialty there, were planning to visit Johns Hopkins. That further served as a vehicle to organize the mission and interweave that together with my personal goals and the SCCM mission and the Ukrainian goal.

Dr. Enfield: I wonder if both of you could reflect a little bit about what were your primary educational goals when you started out, and how do you feel like you achieved those goals while there?

Dr. Díaz-Gómez: I do believe, in these kind of unforeseen circumstances, the most important attribute I have to have in mind is learn how to adapt. So my primary goal was to adapt as much as possible to ensure the Ukrainians receive this course under the high standards that we deliver in the U.S. and other countries already. We have a faculty that can be cohesive, that we can really have genuine team players and be active listeners. I think we were able to prove that because some of the colleagues were coming with questions, so you need somebody who’s really experienced, somebody who’s trying to be in that person’s shoes and really adapt and provide as much education as we can.

One of our faculty was Ukrainian and was probably one of the first people I thought about when David Martin called me. His name is Vadim Gudzenko. He was my co-fellow when we were chosen at Mass General Hospital in Boston in 2009. Vadim really inspired me, even staying for an additional half an hour or an hour because he really wanted to give back to his people as much knowledge as he can. So, once again, the main goal is how to adapt. We know we have a great product, how we can deliver the product in Ukrainian, English, via active listeners, and adjust to whatever their needs were.

Dr. Enfield: Aliaksei, anything you want to add to that?

Dr. Pustavoitau: José hit the high points, that delivery of a high-quality product and education were the first and foremost priority. But on top of that, there’s an opportunity to establish a longitudinal relationship, not just to train people to take the probe and scan but actually to build a sustainable system and infrastructure or provide knowledge on that for longer-term advancement of critical care ultrasonography in the country.

Dr. Enfield: I can only imagine, you were going into an active war zone. There were probably many barriers and difficulties you had to overcome. Maybe starting with Aliaksei, what were the challenges that you faced bringing this program to Ukraine and delivering it?

Dr. Pustavoitau: The city selected was Lviv, which is in the western part of Ukraine, which is least likely to be in the active war zone, although Russia has long-range ballistic missiles, which are able to reach pretty much any point in the country, so the risk is not zero. But nonetheless, work was done to ensure the safety of both participants as well as the trainers to do all the courses in a sheltered environment, which would be protective of both learners and trainers, as well as transportation in and out of the country. Since there’s no active fly zone in and out of the country, everything has to be arranged by train.

Then, the rail systems are different, so you have to switch train connections at the border. You come to one town at the border of Poland and Ukraine, switch the train there, and get in and around the city also when people, for the most part, don’t know the language, so, those big things. Second is really delivering the message that the Ukrainians need to hear and adapting, just like José mentioned, to the local culture and an extremely hierarchical and state-run healthcare system. The final challenge is the language barrier.

Dr. Enfield: You mentioned the difference in the healthcare system there being very hierarchical. I wonder if you could briefly talk about, José, who were the participants receiving this education? Who were you teaching in this course?

Dr. Díaz-Gómez: Another crucial individual in this mission is my dear colleague and friend, Dr. Pustavoitau. He had a very good relationship already with Dr. Sergii Dubrov, who is minister of health first deputy and an anesthesiologist intensivist. Actually, he visited Aliaksei at Johns Hopkins. That was the initial stage in preparation for the mission. That gave us a tremendous opportunity to have better communication with those people who are going to need this intervention. He worked very closely with Colleen McNamara, developing lists. Then we could organize groups because we are very organized when we delivered the course in the United States.

When describing hierarchical, I can tell you a very beautiful story. We trained over 150 individuals but we only had 80 butterflies, and those butterflies primarily were assigned to those people who were in academic places or in places that probably had recognized that they have a high burden of patients. But there was this colleague, it was a familiar colleague, who came crying, begging for one ultrasound, and she told me she was working in a rural area, and I’m pleased that she was the only doctor. She almost brought tears to my eyes. I couldn’t resist, and I talked to Colleen, and Colleen had an extra one. We gave it to her.

So I do agree with Aliaksei, that hierarchical system, it took us a while to figure out how to really give everyone as much as we could, regardless what their position was, academic, nonacademic, rural, or being in the capital of Kyiv, that to me, there were very talented, very smart people in those institutions in Kyiv. I predict there will be leaders in a collaboration that Aliaksei is leading right now.

Dr. Enfield: Thinking about that, I wonder if there were specific areas that you were really focused on, making sure the learners really got those concepts, thinking about resuscitation and other aspects of critical care ultrasound. Were there any differences of what you focused on because of the ongoing war, or did you all stick to the course that we typically see SCCM deliver?

Dr. Pustavoitau: For the most part, the focus was on resuscitative techniques. Simultaneously with the course, just a little bit earlier than that, we started surveying people who participated in courses prior and during the course. So we knew the highest used ultrasound applications were FAST exam for assessment for bleeding and resuscitative techniques, as well as procedural support like vascular access. Surprisingly, also regional anesthesia was high on the list. But data are in completely different forms at this point. Nonetheless, the demand was clearly there. To deliver that, one needs not only knowledge and skills. One needs devices and access to the potential recordings of those. The patients people evaluate can be looked through by themselves as well as their colleagues and help them provide useful feedback. So the entire infrastructure built into learning is what makes it really important.

Dr. Enfield: I wonder if you could elaborate, José, on any other success stories you had during the mission, things that really stood out to you of high points of what you brought to Ukraine or high points of what you brought home to yourself?

Dr. Díaz-Gómez: Perhaps the best part of the experience for me was confirming the immediate effect of our critical care ultrasound education. Several Ukrainian colleagues, including those on the front line, shared images and clips with good diagnostic accuracy within days after we left. They were impacting medical care directly. That’s much different than other medical fields trying to analyze data, etc. We at least need to care for this immediate effect on humanity, and that’s something we really master at SCCM. We try to always put products that really empower people within a week. When they go back to their workplaces, they can implement something. They can see real effect.

However, I have to say we aren’t done yet. The other part that really inspired me is collaborating with Aliaksei and other academic clinicians in the United States, because I do agree with him that we basically build that cadre of individuals that we consider training the trainers. I would love to see in the coming years some of those individuals teaching us, showing us something we haven’t described. Some of them might be able even to develop their own guidance in their country or, why not, original publications or, why not, even coming to the U.S. and demonstrating to us different values of the tools that we haven’t been able to recognize in the continental U.S.

Dr. Enfield: It’s a lot to take back. I do want to follow up on something Aliaksei said earlier, which was this longitudinal program. I wonder if you might elaborate about what you mean by that and what you see coming in the future through that program.

Dr. Pustavoitau: What I really mean is that when you build a system that allows people to save images and potentially interpretations like a cloud-based system, you’re able to actually review those images together. The way I would see that is the Ukrainian colleagues and us here in the United States, any other countries actually who are willing to participate and review each other’s images and provide comments and bring people up to the same sort of standards that are everywhere else. That’s what I call the sustainable system. Then since the courses were held in March, actually, we were in touch with some of our colleagues who took the courses, and we were able to provide feedback on what images they collect and the quality of the images, quality of interpretation. That’s the longitudinal.

As far as what José mentioned, training the trainers, that’s a very important concept. It comes back to the very old saying, right? I mean, first you see one, you do one, and then you teach one. I think once they start teaching themselves, they will rapidly escalate the number of actual users, and that is really supported through organized teaching.

Dr. Enfield: I wondered, José, if you could speak to the challenges from a logistics standpoint of running this course, just briefly.

Dr. Díaz-Gómez: Certainly. Translating to Ukrainian requires us to use our expertise and deliver basically critical educational points to maximize time utilization. Because I was speaking, and then I have a translator, an interpreter doing the translations. So we were able to really select the most important educational points.

Their ultrasound devices sometimes needed to get fixed, or even there was an ultrasound device in another language, in German. Honestly, I don’t know German, so it was hard. The first time one of the sirens, the alarm went off, I felt an enormous sense of responsibility and anxiety. Allowing me to be closer to my colleagues and SCCM staff and trying to learn how to deal with that kind of situation over time, we became more comfortable.

Lastly, we were trying to really maximize the utilization of the iPads and the butterflies we gave to each of the participants. That actually gave us another opportunity, which was to bring back some report to the high leadership of SCCM and Direct Relief. Based on that, they will be willing to support further the Ukrainians.

Dr. Enfield: Speaking of that, I wonder if you all can speak to any upcoming missions that SCCM might have either in supporting ultrasound education or otherwise to Ukraine or elsewhere?

Dr. Díaz-Gómez: Yes, we will go back. They need us. I can see now with this globalization we have in SCCM its real momentum. I’m aware of other missions on different continents. I can envision how global SCCM will have a really good pipeline with these initial lessons learned in Ukraine. But right now, in the immediate future, we’re going to continue supporting the Ukrainians training the trainers.

Dr. Enfield: Wonderful. I wonder, Aliaksei, if you could mention how others might get involved who are hearing this podcast and really feeling inspired or asking themselves is this something they could also participate in?

Dr. Pustavoitau: Ukraine in general would like to become part of the western world, and it’s a long-term project even after the war is over. Any involvement is welcome. There are multiple charity organizations as well as professional organizations; people can support the country. Reaching out, I think, to both of us, José and I, for this particular type of work would be of great help. Organizations that José mentioned, like Direct Relief, SCCM, people involved there with this project, Colleen McNamara, Theresa Woike, Ken Klarich, all the people can provide guidance how to join the group, how to support it by other means.

Dr. Enfield: Before we wrap up, I just wanted to ask you both, how has this experience changed you, and what did you take away from it?

Dr. Pustavoitau: Really being humble because, I mean, you don’t realize how blessed we are here in the United States for what we have. But on the other hand, it’s part of the concept of actually paying it forward, that being grateful for what you have, you want others to reach the same sort of heights and goals. In a big way, it’s a humanitarian effort.

Dr. Enfield: José, what about you?

Dr. Díaz-Gómez: Personally, the sense of humanity went to the next level. I never heard any of these colleagues mentioning something about the enemy. All I heard was they really wanted to help people who were injured, people who have illnesses that needed to be addressed. That was really inspirational. That actually takes away any political component, anything like that, and that brings the collegiality and the medical profession to the next level because, actually, I saw a really impressive interaction, interprofessional interaction between paramedics, physicians, and people from different specialties and different backgrounds. That was huge.

The second aspect, and I cannot be more thankful, I am an immigrant from a country that was in a kind of war, which was in Colombia in the ‘80s, and there is still some violence. But you never prepare for any kind of situation like this where everything can be unprecedented and things unfold in a way that you cannot control. However, in this specific mission, just having the SCCM staff both here in the United States and in Ukraine with the support they provided to us, I’m ready for any mission for SCCM globally. Even now, because I want to go, I can actually even be a mentor for those future leaders who need to go. But I will tell you, having Theresa Woike at 3:00 a.m. in the morning, starting in Chicago, guiding us on logistics, or Ariel, and then having Colleen McNamara inside with Ken Klarich, I felt I was pretty much ready to react, to adapt to anything we needed. Those two things, the value of SCCM staff and the humanity at the next level, were my most, I would say, lifelong experiences for me after going to Ukraine.

Dr. Enfield: Well, I want to thank you both for what you did and also taking the time today to record this podcast. This concludes another episode of the Society of Critical Care Medicine Podcast. If you’re listening on your favorite podcast app and you like what you heard, consider writing and leaving a review. For the Society of Critical Care Medicine Podcast, I’m Kyle Enfield.

Kyle B. Enfield, MD, FSHEA, FCCM, is an associate professor of medicine in the Division of Pulmonary and Critical Care at the University of Virginia. He received his undergraduate degree from the University of Oklahoma.

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