04-Characteristics of Medical Evacuation by Train in Ukraine, 2022.

<img src="/media/202408//1724838573.903371.jpeg" />JAMA Network<img src="/media/202408//1724838573.9083111.png" />en TM<img src="/media/202408//1724838573.927755.png" />Original Investigation | Global HealthCharacteristics of Medical Evacuation by Train in Ukraine, 2022Stig Walravens, MD; AlbinaZharkova, MD, PhD; Anja DeWeggheleire, MD, MPH; Marie Burton, MPH; Jean-Clément Cabrol, MD; James S. Lee, MD, MSc<table><tr><td rowspan="2">AbstractIMPORTANCE The 2022 war in Ukraine severely affected access to health care for patients in the conflict-affected regions and limited options for medical evacuation. Air transport, a commonmethod of medical evacuation in war zones, was unsafe due to the conflict of 2 modernized military forces that were in possession of aircraft and surface-to-air weapons; therefore, Médecins SansFrontières, in collaboration with the Ukrainian railway company and Ukrainian health agencies, addressed this by initiating medical evacuation via medically customized trains.OBJECTIVE To describe the implementation of medical evacuation trains aimed at improving the access to health care for war-affected patients.DESIGN, SETTING, AND PARTICIPANTS This case series describes the remodeling of 2 trains used for medical evacuation in a conflict zone during the war in Ukraine. The study was conducted from March 30 to November 30, 2022. One train had minimal adjustments and could be rapidly deployed to address the most pressing humanitarian needs, while the other underwent major structuralmodifications to provide intensive care capacity. The report details the medical capabilities of thetrains, the organization of referrals, and operational challenges encountered. Additionally, it includes a case series on the characteristics of patients transported in the initial 8 months,based on routinely collected programmatic descriptive data of all patients transported by the medical trains.RESULTS In 8 months, 2481 patients (male-female ratio, 1.07; male, 1136 [46%]; female 1058 [43%];missing data, 287 [12%]; median age, 63 years [range, 0-98 years]) were evacuated from 11 cities near the Ukrainian conflict frontline to safer areas. Initially, the trains predominantly evacuated trauma patients,but over the course of the war, the patient characteristics changed with more medical and nonacute conditions, and fewer trauma patients. The main reason for entry into the intensive care unit train carriage was for close monitoring and observation, and the maininterventions performed were primarily for respiratory failure.CONCLUSIONS AND RELEVANCE The findings of this study suggest that medical evacuation in a war zone by converted trains is possible and can improve access to health care for war-affectedpatients. The presence of intensive care capacity on board allows for transport of more severely ill or injured individuals. However, the target population should not be limited to trauma patients, ashealth care institutions affected host a much broader population whose needs and urgency for evacuation may change over time.JAMA Network Open. 2023;6(6):e2319726. doi<a href="https://jama.jamanetwork.com/article.aspx?doi=10.1001/jamanetworkopen.2023.19726&amp;utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamanetworkopen.2023.19726">:10.1001/jamanetworkopen.2023.19726</a><img src="/media/202408//1724838573.9759989.png" /> Open Access. This is an open access article distributed under the terms of the CC-BY License.</td><td>Key PointsQuestion How can medical evacuation trains be implemented in a war zoneand what type of patients can be expected?Findings This case series describesmedical evacuation by train during the 2022 Ukraine conflict using 2 trains.Over 8 months, the medical trains made 74 journeys, evacuating 2481 patientsfrom 11 cities close to the frontline;during this period, the most common type of patients transported changed from trauma-related casualties topatients with medical and nonacute reasons for referral.Meaning The findings of this studysuggest that medical evacuation by train can be feasible in a conflict zone with a preexisting railway network, if adapted to local conditions and an evolvingpatient population.</td></tr><tr><td>+ <a href="https://jama.jamanetwork.com/article.aspx?doi=10.1001/jamanetworkopen.2023.19687&amp;utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamanetworkopen.2023.19726">Invited Commentary</a> + <a href="https://jama.jamanetwork.com/article.aspx?doi=10.1001/jamanetworkopen.2023.19726&amp;utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamanetworkopen.2023.19726">Supplemental content</a>Author affiliations and article information are listed at the end of this article.</td></tr></table>JAMA Network Open. 2023;6(6):e2319726. doi:10.1001/jamanetworkopen.2023.19726 June 23, 2023 1/9Downloaded from jamanetwork.com by guest on 11/30/2023JAMA Network Open | Global Health Characteristics of Medical Evacuation by Train in Ukraine, 2022IntroductionAt the first anniversary of the 2022 war in Ukraine, a report of the office of the High Commissioner for Human Rights reported 21580 civilian casualties of whom 8101 were killed, noting the actual figurescould be considerably higher due to minimal information from areas most under siege.1 Access to safe and essential medical care near the frontline was severely compromised due to activeweaponized combat and limited transportation options due to roadblocks, damaged roads, and collapsed bridges. Health care staff fled, hundreds of health care facilities were attacked, and the remaining functional medical services were overwhelmed with trauma patients.2-4 Moreover, the initial mass evacuations of affected areas often left older, sick, or institutionalized people behind without continuity of care, which sooner or later put them in a situation that required medicalevacuation.5-7Médecins Sans Frontières (MSF), an independent, medical humanitarian organization alreadypresent in Ukraine before the war, explored ways to relieve overcrowded hospitals and bring conflict- affected patients to safer regions. Air transport, the most frequently reported technique of medical evacuation in war zones,8 was unsafe due to the conflict of 2 modernized military forces possessing aircraft and surface-to-air weapons. Furthermore, the airspace was closed to civilian aircraft.Evacuation by road had inherent challenges due to long distances, frequent roadblocks, and greater need for human and material resources. However, Ukraine’s railway system was initially onlyminimally affected, allowing for the transportation of larger numbers of patients to safe areas.Minimal literature exists on this alternative evacuation modality. The last large-scale wartime medical evacuation by train took place during the Korean conflict of 1950 to 1953.9 However, more recently, train transport of patients with COVID-19 to intensive care units (ICUs) happened in France.10This study describes a program of medical evacuation by train aimed at improving access tohealth care for war-affected patients. It reports on the remodeling of 2 trains for medical use,including 1 with ICU capacity, staffing, patientselection, train routeselection, organization ofreferrals, and associated operational challenges. Additionally, it includes a case series on thecharacteristics of patients transported in the initial 8 months, need for referral, and the type of care provided.Program DescriptionTrain AdaptationsThe medical and logistic department of the MSF drafted feasibility, technical, and strategic plans, and consulted local stakeholders. In collaboration with the National Ukrainian railway company, 2Ukrainian-made passenger trains were adapted to prepare them for medical transport. Remodeling was guided by previous experience with COVID-19 trains in France.10 However, aspects of war and the local context needed to betaken into consideration.The basic medical train had minimal modifications and was launched to respond quickly to the most pressing humanitarian needs. It consisted of 2 sleeper carriages with modified partitions toallow stretchers to enter, 1 sleeper carriage for ambulatory patients with less severe conditions, and 1 staff carriage. Patients’ companions could stay in the upper bunk beds or in unoccupied lower beds. The train was equipped with medications and materials, oxygen concentrators, suctioning, andemergency equipment for intubation or chest drains. Up to 32 immobile patients and 27 ambulatory patients could be transferred.While the basic train was put in use on March 31, 2022, construction of a more advancedmedical train with ICU capacity was still under way (eFigure in<a href="https://jama.jamanetwork.com/article.aspx?doi=10.1001/jamanetworkopen.2023.19726&amp;utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamanetworkopen.2023.19726">Supplement 1</a>). Extensive remodeling was performed, modifying the electrical system and stripping the interior to accommodate hospital beds and equipment. The train consisted of 8 carriages: 1 carriage with 5 ICU beds of which 2 could offer invasive mechanical ventilation, 2 carriages with 9 beds for nonambulatory patients, 1 regular sleeper carriage, and 1 carriage with beds and mattresses for ambulatory patients with nonsevere conditions and their companions. The 3 remaining carriages were for staff, medical stock, oxygen<img src="/media/202408//1724838573.9949079.png" /> JAMA Network Open. 2023;6(6):e2319726. doi:10.1001/jamanetworkopen.2023.19726 June 23, 2023 2/9Downloaded from jamanetwork.com by guest on 11/30/2023JAMA Network Open | Global Health Characteristics of Medical Evacuation by Train in Ukraine, 2022generators, and an uninterruptable power supply, which was needed to allow transport of ICUpatients over long distances on an unreliable electrical railway grid. Exclusive use of oxygen cylinders was deliberately not considered as the train risked being stuck for long periods in case of damaged railway infrastructure and would carry a high explosive risk in a war zone. The oxygen-generatingsystem could provide oxygen at a rate of 30 L/minto each ICU bed, while the 2 ICU beds withmechanical ventilation were able to provide 60 L/min and constant pressure between 2.8 and 6.0 bars needed for the ventilator. The structural changes, technical modifications, and equipmentinstallations of the advanced medical train took 23 days, and first deployment happened on April 24, 2022. Minor adjustments continued after train deployment. Air conditioning was installed in thespring, while the oxygen carriage was equipped with electrical heating and thermally insulated oxygen pipes for winter temperatures to preserve the functioning of oxygen generators, which highlights the importance of being able to further modify the trains after deployment to react to encountered or anticipated problems.Train StaffApart from a few MSF international staff, it was mainly local individuals who were recruited to staff the train. These were physicians with ICU experience, nurses, nurse aides, technical logisticians, and a translator. The number of staff increased over time, allowing more rotations and more nurses per patient. International staff consisted of a project coordinator, an emergency/ICU physician, a nurse manager, and once the advanced train was launched, an ICU nurse. Local staff were trained togradually take over some of these positions. Ukrainian Railway staff remained in charge of routine train functioning and movements.Patient and Train RouteSelectionThe number and severity of patients referred needed to be considered when accepting a transfer.Patients required a certain clinical stability for transport as a 1-way trip lasted, on average, 21 hoursand advanced diagnostic or therapeutic options on the train were limited. Initially, the capacities of the train were not well known to the referring institutions. As a result, the number and/or acuity of the patients was often higher than anticipated. Because the train’s medical staff was responsible for the health of patients once they were on board, urgent medical and ethical decisions whether toaccept patients for transport often had to be made on the platform. Acceptance meant exposing the patient to a long train journey with constraints in space, ICU capacity, and access to life-savingsurgery, while refusal meant sending the patient back to the referring hospital where conditions were not well known. The implementation of referral guidelines, which were distributed to the Ministry of Health of Ukraine, regional departments of health and referring hospitals (eAppendix 1 andeAppendix 2 in<a href="https://jama.jamanetwork.com/article.aspx?doi=10.1001/jamanetworkopen.2023.19726&amp;utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamanetworkopen.2023.19726">Supplement 1</a>) improved this process considerably. In general, the basic medical train accepted patients of all ages in stable condition and without ICU requirement. Patients receivingoxygen were allowed if their baseline usage was less than 5 L/min. With deployment of the advanced train, more critically ill patients could be accepted, and criteria were extended to patients receiving vasopressors or mechanical ventilation.Initially, the Ministry of Health of Ukraine assisted in identifying patients for transport andfunctioned as liaison with the different referring and accepting departments of health, hospitals, and institutions. They collected information on potential candidates, arranged transport to and from the railway stations, and helped organize appropriate distribution of patients to different receivinghealth care facilities. Subsequently, MSF established the position of medical liaison, a local MSFphysician with experience on the evacuation train, based in the eastern city of Dnipro. The liaisoncollaborated closely with the Ministry of Health representative in establishing patient lists, verifying the suitability of every proposed patient transfer, checking bed availability on the train, andimproving communications. After 3 months, the medical liaison was well established and dealtdirectly with the various regional departments of health for both referral and acceptance of patients.<img src="/media/202408//1724838574.008918.png" /> JAMA Network Open. 2023;6(6):e2319726. doi:10.1001/jamanetworkopen.2023.19726 June 23, 2023 3/9Downloaded from jamanetwork.com by guest on 11/30/2023JAMA Network Open | Global Health Characteristics of Medical Evacuation by Train in Ukraine, 2022Once health care facilities most in need were identified, a train route itinerary was planned.Together with the railway company, the closest accessible railway station was sought, securitysituation assessed, and timetable set. Initially, train routes were set only 1 or 2 days before departure, allowing maximum adaptability to respond to the most pressing humanitarian needs. Nevertheless, this system was strenuous for the railway company to fit it into a busy railway network and forreferring hospitals to identify and prepare their patients for transfer on time. Gradually, the planning of train routes evolved into a mixed system that also included preplanned and repetitive visits tocertain regions. This helped large referral hospitals to plan ahead and allowed for the evacuation of institutions such as an orphanage and psychiatric institutions. The medical liaison identifiedinstitutions requiring urgent evacuation and institutions that could accept the specific type of patients being evacuated.Organization of the ReferralThe train mostly left the base city of Lviv in the afternoon and planned to arrive the next day around midday. Embarkment of patients needed to be carefully planned as time on the platform wasrestricted due to safety risks. To illustrate why, less than a day after the basic train evacuated 40 patients from Kramatorsk, multiple rockets hit the same platform, killing at least 50 individuals.11During the outward journey, staff prepared the train for the arrival of patients. Physiciansassessed the list of planned patients and anticipated the severity and type of care needed to allocate beds and resources properly. Shortly before arrival of the train, patients were transferred from the health facilities to the railway station. Ideally, ambulances queued up at the platform on arrival.Nevertheless,the security situation and limited availability of ambulances led to situations in which ambulances were delayed or had to leave for a new assignment before the train arrived. This resulted in major differences in the number of personnel who were present on the platform to help transfer patients onto the train, and sometimes forced the train staff to make quick shifts in embarkmentstrategy in order to allow for a timely departure. The experience of the first embarkmentsled to astandardized embarkment strategy aimed at minimizing time loss in assigning each patient to themost optimal bed position while still being able to adapt to unexpected situations (eAppendix 3 and eAppendix 4 in<a href="https://jama.jamanetwork.com/article.aspx?doi=10.1001/jamanetworkopen.2023.19726&amp;utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamanetworkopen.2023.19726">Supplement 1)</a>. A physician coordinated the embarkment and triaged every patient before entry in the train, while a nurse assigned them to a suitable bed within the carriages. A color- coded tag was pinned to each patient at triage to signal their assigned carriage, which had acorresponding-colored flag at the entrance. The most critical patients were positioned in beds near the nursing station in the basic train or in the ICU carriage in the advanced train. Patients who were ambulatory with less need of nursing care were placed in a regular sleeper carriage. Nonambulatory patients were carried in on a stretcher by ambulance personnel or by MSF staff in their absence. Asspace is restricted in a carriage and limited to 1 entry, stretchers needed to be carried in one-by-one or in series, pressuring time management. The advanced train was more spacious to maneuver insidebut carried fewer nonambulatory patients overall. Furthermore, its length of 8 carriages meant carriages were further apart and could complicate accessibility from some shorter platforms.Once on the train, a thorough assessment of each patient took place, and the necessary medical treatment was continued to allow safe and comfortable transport. All staff were needed in theseinitial busy hours to settle patients and establish a care plan before staff could switch to a shift system in the evening. Specialized treatments relevant for a long transport context were sometimes used, such as peripheral nerve blocks. These were performed to avoid respiratory complications in selected patients with high opioid requirements due to aggravated pain of their injuries by a bumpy, moving train. Diagnostic and therapeutic options remained limited on the basic medical train and, on rareoccasions if patients’ conditions deteriorated, this resulted in an unplanned stop at a railway station en route for an urgent patient transfer to the closest appropriate health care facility. Implementation of the advanced medical train ensured better care of the patients with deteriorating status andallowed for the transport of more critically ill patients, promoting it as the main train used for evacuations.<img src="/media/202408//1724838574.0195022.png" /> JAMA Network Open. 2023;6(6):e2319726. doi:10.1001/jamanetworkopen.2023.19726 June 23, 2023 4/9Downloaded from jamanetwork.com by guest on 11/30/2023JAMA Network Open | Global Health Characteristics of Medical Evacuation by Train in Ukraine, 2022Patient care onboard the trains also differed from regular prehospital transport care in otheraspects. Many patients had been denied access to health services for a long time, and with theincrease in medical and social cases, the staff was frequently engaged in primary health care, such as restarting treatment for chronicmedical comorbidities. Mental health was a major concern for many patients and necessitated training staff on how to assist these patients and how to cope with thestories they heard themselves. Staff actively identified specific social or mental health needs inpatients, which were then followed up by MSF social workers after arrival. They mostly providedassistance on aspects of shelter, links to family, charity and volunteer organizations, social support, or mental health services.In preparation of arrival the next morning, the definite number, severity, type, and mobility of patients needed to be communicated to the Ministry of Health or regional departments of health to allow planning of transport to the receiving hospitals. These institutions in the relatively saferwestern regions of the country had less disrupted health care systems. Nevertheless, a sustained influx of newly evacuated patients could soon overwhelm their capacity.12 Trauma patients whoneeded further surgery or long-term rehabilitation could often be transferred to hospitals abroad facilitated by the European Union Civil Protection Mechanism.13 In contrast, patients with othermedical and social care needs remained predominantly in Ukraine and were consciously dispersed across several western provinces to redistribute the patient load.After disembarkment, an MSF logistical team came on board to remove garbage, replace dirty linen, and restock medical material and drugs. The latter were kept in standardized boxes andreplaced entirely after each trip, not to lose time restocking. A cleaning team cleaned and disinfected the carriage and equipment. A few hours later, the train often left again.MethodsAll patients had demographic and clinical case management data collected as part of routineoperations. These routine programmatic data were anonymized and analyzed for the first 8 months of train deployment (March 30 to November 30, 2022). Patient characteristics and clinical features were summarized using medians and ranges for continuous variables and percentages for categorical variables. Where applicable, this report follows the Strengthening the Reporting of Observationala Missing data of 287 patients. b Missing data of 642 patients.<table><tr><td colspan="4">Table 1. General Information on Train Evacuations and Patient Demographic Characteristics</td></tr><tr><td>Variable</td><td>Basic medical train</td><td>Advanced medical train</td><td>Both trains</td></tr><tr><td>No. of evacuations (%)</td><td>13 (18)</td><td>61 (82)</td><td>74 (100)</td></tr><tr><td>No. of patients (%)</td><td>483 (19)</td><td>1998 (81)</td><td>2481 (100)</td></tr><tr><td>Male/female ratioa</td><td>0.88</td><td>1.12</td><td>1.07</td></tr><tr><td>Median age, y (range)b</td><td>63 (1-94)</td><td>63 (0-98)</td><td>63 (0-98)</td></tr></table>Abbreviation: ICU, intensive care unit.a Medical condition: acute illness; not part of the surgical, trauma, or obstetrics groups.b Nonacute condition: vulnerable population in need of evacuation, but without capabilities to takeregular passenger train due to underlying condition or extremes of age.c Trauma, accidental: burns,falls, traffic, or other accidents.d Trauma, violent: bomb blast, gunshot, edge weapon, landmine, shrapnel, projectile, shelling, or otherviolence.<table><tr><td colspan="4">Table 2. Reasons for Referral</td></tr><tr><td rowspan="2">Variable</td><td colspan="3">No. (%)</td></tr><tr><td>Patients of non-ICU carriages</td><td>Patients of ICU carriage</td><td>All patients</td></tr><tr><td>Medical conditiona</td><td>548 (24)</td><td>57 (30)</td><td>605 (24)</td></tr><tr><td>Nonacute conditionb</td><td>1098 (48)</td><td>0 (0)</td><td>1098 (44)</td></tr><tr><td>Obstetrics</td><td>1 (&lt;1)</td><td>1 (1)</td><td>2 (&lt;1)</td></tr><tr><td>Surgical, nontrauma (%)</td><td>52 (2)</td><td>3 (2)</td><td>55 (2)</td></tr><tr><td colspan="4">Trauma</td></tr><tr><td><img src="/media/202408//1724838574.02999.png" />Accidentalc</td><td>65 (3)</td><td>13 (7)</td><td>78 (3)</td></tr><tr><td><img src="/media/202408//1724838574.033513.png" />Violentd</td><td>513 (22)</td><td>115 (61)</td><td>628 (25)</td></tr><tr><td><img src="/media/202408//1724838574.03635.png" />Unclassified</td><td>15 (1)</td><td>0</td><td>15 (1)</td></tr><tr><td>Total</td><td>2292 (100)</td><td>189 (100)</td><td>2481 (100)</td></tr></table><img src="/media/202408//1724838574.039062.png" /> JAMA Network Open. 2023;6(6):e2319726. doi:10.1001/jamanetworkopen.2023.19726 June 23, 2023 5/9Downloaded from jamanetwork.com by guest on 11/30/2023JAMA Network Open | Global Health Characteristics of Medical Evacuation by Train in Ukraine, 2022Studies in Epidemiology (<a href="https://www.equator-network.org/reporting-guidelines/strobe/">STROBE</a>) reporting guideline for observational studies. This manuscript fulfilled the exemption criteria set by the MSF Ethics Review Board for a posteriori analysis ofroutinely collected clinical data and thus did not require review by the MSF Ethics Review Board. It was conducted with permission of the medical director of MSF Operational Centre Brussels.<table><tr><td>ResultsIn 8 months, the MSF trains made 74 journeys, evacuating 2481 patients from 11 cities close to thefrontline. The median age of transported patients was 63 (range, 0-98) years, and slightly more male patients were evacuated (male-female ratio, 1.07; male, 1136 [46%]; female 1058 [43%]; missingdata, 287 [12%]). Atotal of 1098 patients (44%) were from a vulnerable population with a nonacute condition as the medical reason for referral, 721 patients (29%) had a recent or semirecent trauma,605 patients (24%) had a medical condition, 55 patients (2%) had a nontraumatic surgical condition, and 2 patients (&lt;0.1%) had an obstetric condition. General information on train evacuations andpatient demographic characteristics can be found in Table 1, and Table 2 lists the various reasons for referral. The Figure shows the evolution of the type of reason for referral of the patients. No patient died on the train, 2421 (98%) reached the final destination, and 5 patients (0.2%) left the train ontheir own accord; data were missing for 55 patients (2%). Seven patients were transferred from the train before arrival at destination due to medical deterioration; however, this was not captured in the routine data collection.</td></tr><tr><td>Figure. Reasons for Referral by Medical Train Over Time</td></tr></table><img src="/media/202408//1724838574.04388.png" />A450400350300250200150100500Transported patients, No.Transported patients, No.<img src="/media/202408//1724838574.04816.png" />BAll patientsIncluding 87 babies<table><tr><td colspan="2">patients from <s> </s>Including 269</td><td></td></tr><tr><td colspan="3">psychiatric institution</td></tr><tr><td colspan="3">Including 208 patients from</td></tr><tr><td>and toddlers evacuated</td><td colspan="2">psychiatric institution</td></tr><tr><td colspan="3">from orphanage</td></tr><tr><td colspan="3"></td></tr><tr><td colspan="3"></td></tr><tr><td colspan="3"></td></tr><tr><td colspan="3"><img src="/media/202408//1724838574.0534642.png" /></td></tr></table>March 30 May June July August September October Novemberto April 31Month in 2022Patients in ICU carriage<table><tr><td>35302520151050</td><td><table><tr><td></td></tr><tr><td></td></tr><tr><td></td></tr><tr><td></td></tr><tr><td></td></tr><tr><td></td></tr><tr><td></td></tr></table>April 25 to May 31June JulyAugust September October NovemberMonth in 2022</td></tr></table><table><tr><td>Referred pathology<img src="/media/202408//1724838574.060056.png" /> Medical condition <img src="/media/202408//1724838574.0634549.png" /> Nonacute condition(high-risk population or humanitarianevacuations)<img src="/media/202408//1724838574.0671282.png" /> Surgical (nontrauma)condition<s>	</s> Obstetrics<img src="/media/202408//1724838574.071022.png" /> Trauma accidental(burns, falls, traffic, or other accidents)<img src="/media/202408//1724838574.074378.png" /> Trauma violent (bomb blast, gunshot, edged weapon, landmine,shrapnel or projectile, shelling, or otherviolence)<img src="/media/202408//1724838574.077012.png" /> Trauma unclassified</td></tr></table>Data shown for all patients (A) and patients in the intensive care unit (ICU) carriage (B).<img src="/media/202408//1724838574.090119.png" /> JAMA Network Open. 2023;6(6):e2319726. doi:10.1001/jamanetworkopen.2023.19726 June 23, 2023 6/9Downloaded from jamanetwork.com by guest on 11/30/2023JAMA Network Open | Global Health Characteristics of Medical Evacuation by Train in Ukraine, 2022The main reasons for transport in the ICU carriage (n = 189) were for acute respiratory failure (16%), hemodynamic instability or shock (13%), altered mental status (21%),and metabolicdisturbances (5%). The remainder was for close observation and monitoring (45%). The maininterventions reported inside the ICU train carriage were oxygen administration (n = 41), invasive mechanical ventilation (n = 23),tracheostomy care (n = 18), central line management (n = 33),vasopressors (n = 5), and peripheral nerve blocks (n = 2).<table><tr><td>DiscussionAt the beginning of the conflict, direct trauma cases constituted most of the evacuated patients, but their proportion diminished over time. In the ICU train carriage, trauma continued to be the mainreason for referral over time, although a similar decrease occurred. In part, this could be attributed to the stabilization of the frontline with fewer direct civilian casualties.1,14 Furthermore, other state and nonstate actors started to provide long-distance transport of trauma patients, and hospitals inconflict-affected regions increased their capacity to care for ICU patients. The shift toward vulnerable populations with chronic comorbidities, older individuals, and institutionalized patients could partly be explained by the impairment of health care facilities and services disrupting the continuity ofcare.5,6 However, the reduced number of trauma patients also led to more proactive identification of these vulnerable groups.Throughout the war, referring hospitals still seemed to be capable of performing primarysurgery for trauma and referred, as the guidelines instructed, mostly stabilized patients for less-urgent secondary or tertiary surgery, or for rehabilitation. This is reflected as the main reason for ICU train carriage entry was for close observation and monitoring (45%) and in the minimal need ofvasopressor (3%) treatment. Nevertheless, many of these patients were still critically ill, as 41 patients needed oxygen (22%) and 23 patients (12%) were receiving mechanical ventilation.LimitationsThere are inherent limitations to our reported patient data, which were collected primarily foroperational purposes. These included missing or incorrect data and variability in clinical care, all of which limit the validity of the results.</td></tr><tr><td>ConclusionsThis program report and case series describes how evacuation by means of medicalized trainsimproved access to health care in war-torn Ukraine. Rapid commissioning of a train was achieved by adapting existing carriages for patient transport. However, to increase thelevel of care providedwith ICU capacity, an extensive structural remodeling was performed. Referral guidelines, a medicalliaison, and a flexible embarkment strategy all helped in correct patientselection and improved patient safety on board. In addition, trauma cases constituted most transports at the beginning;however, the disruption of patient care continuity caused a shift toward more medical and nonacute reasons for referral over time and increased the need for primary health, psychological, andsocial care.</td></tr></table>ARTICLE INFORMATIONAccepted for Publication: April 23, 2023.Published: June 23, 2023. doi<a href="https://jama.jamanetwork.com/article.aspx?doi=10.1001/jamanetworkopen.2023.19726&amp;utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamanetworkopen.2023.19726">:10.1001/jamanetworkopen.2023.19726</a>Open Access: This is an open access article distributed under the terms of the<a href="https://jamanetwork.com/pages/cc-by-license-permissions/?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamanetworkopen.2023.19726">CC-BY License.</a> © 2023 Walravens S et al. JAMA Network Open.<img src="/media/202408//1724838574.153787.png" /> JAMA Network Open. 2023;6(6):e2319726. doi:10.1001/jamanetworkopen.2023.19726 June 23, 2023 7/9Downloaded from jamanetwork.com by guest on 11/30/2023JAMA Network Open | Global Health Characteristics of Medical Evacuation by Train in Ukraine, 2022Corresponding Author: James S. Lee, MD, MSc, Medical Department, Médecins Sans Frontières–Operational Centre Brussels, Rue de l'Arbre Bénit 46, 1050 Brussels, Belgium <a href="mailto:james.lee@brussels.msf.org">(james.lee@brussels.msf.org)</a>.Author Affiliations: Medical Department, Médecins Sans Frontières–Operational Centre Brussels, Brussels,Belgium (Walravens, DeWeggheleire, Lee); Department of Emergency Medicine, Ghent University Hospital,Ghent, Belgium(Walravens);Operations Department, Médecins Sans Frontières–Operational Centre Brussels, Lviv, Ukraine (Zharkova); Operations Department, Médecins Sans Frontières–Operational Centre Brussels, Brussels,Belgium (Burton, Cabrol); Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada (Lee).Author Contributions: Drs Walravens and Lee had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.Concept and design: Walravens, DeWeggheleire, Burton, Cabrol, Lee.Acquisition, analysis, or interpretation of data: Walravens, Zharkova, DeWeggheleire, Burton, Lee.Drafting of the manuscript: Walravens, Zharkova, Burton, Cabrol, Lee.Critical revision of the manuscript for important intellectual content: All authors.Statistical analysis: Walravens, Zharkova, Burton, Lee.Administrative, technical, or material support: Walravens, Zharkova, Lee.Supervision: DeWeggheleire, Lee.Conflict of Interest Disclosures: None reported.Data Sharing Statement: See<a href="https://jama.jamanetwork.com/article.aspx?doi=10.1001/jamanetworkopen.2023.19726&amp;utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamanetworkopen.2023.19726">Supplement 2.</a>Additional Contributions: We thank all field staff of Médecins Sans Frontières,the Ukrainian state railwaycompany Ukrzaliznytsia, the Ukrainian Ministry of Health, regional departments of health, regional health carefacilities, and ambulance services for making this project possible. We thank Mr Christopher Stokes, MSc; MrsKateryna Serbina, BA; and Mrs Melissa How, BSN (Médecins sans Frontières-Operational Centre Brussels),for their ongoing support to the project. We thank Mrs DoraNaliesna(allwith Médecins sans Frontières-Operational Centre Brussels) and Mr Richard Palmer (Richard Palmer Graphics) for the illustration of the advanced medical train. Wethank all departments from Médecins Sans Frontières–Operational Centre Brussels and all advisors we have communicated with for their guidance and support.REFERENCES1. Office of the United Nations High Commissioner for Human Rights. Ukraine: civilian casualty update 27 February2023. February 27, 2023. Accessed April 13, 2023.<a href="https://www.ohchr.org/en/news/2023/02/ukraine-civilian-casualty-update-27-february-2023">https://www.ohchr.org/en/news/2023/02/ukraine-civilian-</a> <a href="https://www.ohchr.org/en/news/2023/02/ukraine-civilian-casualty-update-27-february-2023">casualty-update-27-february-2023</a>2. 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Accessed January 5,2023.<a href="https://www.bellingcat.com/news/2022/04/14/russias-kramatorsk-facts-versus-the-evidence">https://www.bellingcat.com/news/2022/04/14/russias-kramatorsk-facts-versus-the-evidence</a><img src="/media/202408//1724838574.205133.png" /> JAMA Network Open. 2023;6(6):e2319726. doi:10.1001/jamanetworkopen.2023.19726 June 23, 2023 8/9Downloaded from jamanetwork.com by guest on 11/30/2023JAMA Network Open | Global Health Characteristics of Medical Evacuation by Train in Ukraine, 202212. CundyA. “He should have lived”: shortages are proving fatal in Lviv’s hospitals. The Guardian. April 26, 2022. Accessed January 5, 2023.<a href="https://www.theguardian.com/global-development/2022/apr/26/shortages-proving-fatal-in-lviv-hospitals">https://www.theguardian.com/global-development/2022/apr/26/shortages-proving-</a> <a href="https://www.theguardian.com/global-development/2022/apr/26/shortages-proving-fatal-in-lviv-hospitals">fatal-in-lviv-hospitals</a>13. EU preparedness to welcome those fleeing the war in Ukraine. European Commission. March 23, 2022.Accessed January 5, 2023.<a href="https://ec.europa.eu/migrant-integration/news/ec-communication-welcoming-those-fleeing-war-ukraine-readying-europe-meet-needs_en">https://ec.europa.eu/migrant-integration/news/ec-communication-welcoming-those-</a> <a href="https://ec.europa.eu/migrant-integration/news/ec-communication-welcoming-those-fleeing-war-ukraine-readying-europe-meet-needs_en">fleeing-war-ukraine-readying-europe-meet-needs_en</a>14. Barros G, Stepanenko K, Bergeron T. Interactive map: Russia’s invasion of Ukraine. Institute for the Study ofWar and the American Enterprise Institute’s Critical Threats Project. May 23, 2022. Accessed January 5, 2023.<a href="https://arcg.is/09O0OS">https://</a> <a href="https://arcg.is/09O0OS">arcg.is/09O0OS</a>SUPPLEMENT 1.eFigure. Detailed Diagram of the Set-up of the Carriages for the Advanced Medical TraineAppendix 1. Information Leaflet Basic Medical Evacuation Train MSF—Version April 2022eAppendix 2. Information Leaflet Advanced Medical Evacuation Train MSF—Version May 2022 eAppendix 3. Embarkment of Basic Medical Evacuation Train MSF—Version April 2022eAppendix 4. Embarkment of Advanced Medical Evacuation Train MSF—Version May 2022SUPPLEMENT 2.Data Sharing Statement<img src="/media/202408//1724838574.2806091.png" /> JAMA Network Open. 2023;6(6):e2319726. doi:10.1001/jamanetworkopen.2023.19726 June 23, 2023 9/9Downloaded from jamanetwork.com by guest on 11/30/2023