Strengthening Trauma Care Capacity with Remote Training in Ukraine

Shawn M. D’Andrea MD, MPH, FACEP

Introduction
The war in Ukraine has caused a profound humanitarian crisis, with trauma patients exceeding the nation’s healthcare capacity. Responding to the ongoing need in May 2022, the Swiss Foundation for Innovation (SFI) collaborated with the Ukraine Ministry of Health (MOH) to develop a concept for an online tactical trauma care training course. Partnering with the University of New Mexico (UNM) Project ECHO, the Armed Conflict Trauma Training (ACTT) course was rapidly coordinated and deployed to Ukraine, bringing trauma care training to healthcare workers with little or no prior trauma experience. The course was coordinated and implemented in under three weeks.

Course content focused on basic principles of trauma care. While a range of comprehensive trauma training programs such as ATLS and Tactical Combat Casualty Care exist which could meet the objectives of the program, the WHO / ICRC Basic Emergency Care (BEC) trauma module provided a scope and quantity of information well-matched to the teaching objectives and time allotted for the course and served as the template for the program. The ACTT course was organized into 16 one-hour sessions following the BEC trauma content. 

A wide range of organizations and individual subject-matter experts (SMEs) were consulted for input on course content. Experts from academic institutions and organizations including, but not limited to, ACEP, Harvard Humanitarian initiative, Brigham and Women’s Hospital, CDC, WHO, ICRC, IMC, MSF, and ASPR provided input and resources as the course was coordinated. 

Instructor Recruitment
The WHO / ICRC BEC course has a large global network of instructors. The diverse instructor pool added broad experience and perspective, with faculty joining from 4 continents. In addition to BEC instructors, SMEs from multiple academic centers participated as trainers. Several sessions expanded beyond lecture format to include skills demonstration.

Course Logistics
The SFI team supported logistics on the ground during the early weeks of the program. Project ECHO co-lead program development, coordination, and provided technical support. Zoom webinar was chosen over the meeting format due to security concerns of sharing participant location and identity.  Simultaneous Ukrainian interpretation was provided, and each program was recorded and posted on a dedicated YouTube channel. Ukraine MOH provided outreach to recruit healthcare workers to attend the programs. Each session was moderated by the course co-directors. WhatsApp and Telegram messenger groups were created, and shared with participants, to disseminate trauma care resources and course announcements.

Mental Health Trauma
A key element of the program was the mental health trauma content included in each session. Faculty from the Uniformed Services University Center for Deployment Psychology provided a lecture following each trauma presentation and whenever possible the mental health subject was linked to the content in the trauma lecture. The final session of the course was a dedicated, one-hour, mental health trauma program. The subject matter was broad and included considerations for mental health trauma of both patients and care providers. 

Participation and Evaluation
Over 16 sessions, 238 participants joined the program, with a total of 758 attendances. Feedback for the sessions was largely positive, with respondents reporting an increase in knowledge of principles of trauma care and 89% of participants stating they would recommend the course to colleagues. Participation peaked with the first session and a decline in attendance was noted throughout the program, though post-session evaluations did not uncover a clear cause of the decline in attendance.

Considerations for Future Training
The ACTT program was rapidly coordinated and deployed to healthcare workers in Ukraine. While in-person training has many advantages such as nuanced engagement with participants and hands-on skills instruction which are valuable elements of training, benefits of remote programs include the speed of deployment, a pool of rapidly available instructors, limited on-the-ground personnel, and reduced cost. Along with in-person training, remote training should be considered as a strategy to improve trauma care capacity for health systems in settings of humanitarian crises. Hybrid in-person - remote programs may offer additional, additive, benefits of both models of trauma care training.