CRITICAL CARE

By Andrea Kott, MPH

Andrew Scanlon, DNP ’10, at the rehabilitation hospital in Ukraine where he taught clinicians to care for veterans with traumatic spinal cord and brain injuries.

in nursing exist in Ukraine, there were only two nurses with such a degree at the hospital where he worked. What’s more, he says, the country has no NPs. “They definitely have a skill shortage.”

With the help of a translator, Scanlon taught a two-week course for the hospital’s 80 nurses. He covered general nursing skills, infection control, patient transfers, wound care, and issues specific to traumatic brain and spinal cord injuries, including general neuroscience and bladder and bowel care.

The hospital lacked more than skilled staff. Also in short supply were basic medical supplies, like gauze swabs. “One of the things the nurses taught me was how to make gauze squares for dressings, which we take for granted in the U.S. and Australia,” Scanlon says. “I felt embarrassed comparing what we have to what they have. . . . In U.S. or Australian hospitals, we can just grab or order what we need. In Ukraine, they have to rely a lot on donations from international organizations, which aren’t guaranteed, so they have to make do with what they’ve got.”

For Barton, however, given his background in rural emergency medicine, making do was nothing new. “I’m used to providing care with few resources,” he says. His fellowship training in rural emergency medicine and his years of first-responder experience had accustomed him to traveling with a personal supply kit outfitted for providing care in low-resource settings. It contains, among other things, water purification tablets; a flashlight; a giant needle to reinflate a collapsed lung; and a Butterfly IQ, a hand-held point of care ultrasound (or POCUS) machine. Barton uses the POCUS to quickly examine a patient’s heart, aorta, lungs, internal organs, and bladder; to determine the severity and extent of injuries; to insert IVs, central lines, and regional nerve blocks; and to rule out conditions like collapsed lungs. “If I can have one diagnostic tool, that’s what I want,” he says.

He relied heavily on his supply kit in the field hospital, which lacked diagnostic equipment as well as emergency medicine physicians. “In Ukraine, there are no emergency medicine doctors, no emergency rooms. Patients are simply assessed by a surgeon who decides whether they need surgery,” Barton says. “We had a Czech X-ray machine from 1986 and a monitor for blood pressure and pulse oximetry, neither of which were used during my time there, but no lab work or CT scanner—just a giant magnet that looked like a police baton that doctors waved over patients to see if shrapnel under their skin would pop up,” he says.

Shrapnel injuries are very common in Ukraine. “This isn’t a war of gunshots,” Barton says. “It’s a war of artillery, shrapnel, and blast injuries.” Bombs, rockets, shells, and land mines can cause significant chest trauma and collapsed lungs, as well as traumatic brain and spinal cord injuries. “They’re not designed to kill people but to devastate limbs so a person can never fight again,” he adds. “It’s unbelievable how horrendous they are.” Barton and the other volunteers he served with— a former U.S. Special Forces trauma surgeon, a former U.S. Navy SEAL, and an Italian former special forces medic—used his POCUS to assess all the trauma they encountered. “We have a formula to go through trauma medicine in the U.S.,” Barton says. “We check airway, breathing, and circulation; do a primary POCUS survey for life-threatening injuries; and then do a secondary POCUS survey of everything else—systematically moving down from head to toe to rapidly stabilize patients. By the time you reach the toes, you’ve done everything and move on to the next patient.”

Yet when it came to intubating patients, placing chest tubes or central lines, and even drilling a burr hole to relieve the pressure of a brain bleed, Barton often had to rely merely on his knowledge of anatomy and his physical assessment skills. “In Ukraine, when somebody was hurt, the message you got was ‘Fix them.’ You had to go off your gut and knowledge. It made me a lot more confident as a clinician,” he adds.

Unlike the veterans whom Scanlon treated in the rehab hospital, most of Barton’s patients were civilian males ranging from their late teens to their mid-40s or -50s. “They were IT professionals, entrepreneurs, chefs, teachers, and delivery drivers who joined the military because they wanted to defend their country,” Barton says. “They were making amazing sacrifices, hadn’t seen their family for months, and put themselves in danger because they believed in their country and wanted to protect the people they love.”

Now, as Ukraine’s war enters its second year and mass casualties mount, Scanlon and Barton are both planning to return. They will go back full of gratitude for their Columbia education and the way it has thoroughly qualified them to treat patients and train other providers in a war zone.

“I owe Columbia for sparking a fire in me to do more for nursing, and to show me that I can contribute more internationally and nationally,” says Scanlon. The second phase of the WHO program will focus on training nurses and other providers to rehabilitate patients in hospitals across Ukraine. Barton will either rejoin WHO or sign on with another program that needs his skills. “Sometimes we look at health care as a human right in the context of developing nations or inner-city projects,” he says, “but it is also a human right in war zones, where people deserve compassionate, evidencebased, skilled care.

“Nurse practitioners are experts at this,” Barton declares, “and it feels very powerful, as a representative of the international community, to show we care and want to help.” 