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16 19 dec08ukraine

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  • 1. Feature – Ukraine Driving a hard road down in Ukraine Travelling through western Ukraine searching out old and interesting anaesthetic apparatus. Introduction I am a regular visitor to Ukrainian health- care establishments, and as an ODP I have developed a keen interest in the anaesthesia platforms and apparatus that they use. Many of the older ‘warriors’, like the Drager portable battlefield machine in Figure 1, which have served with distinc- tion for many years at the Regional hospital in Ternopil, are being gradually relieved from frontline duty. Nevertheless, many other interesting items still remain on active service in some of the smaller John Allwood SODP satellite and rural hospitals. SODP West Middlesex University So, with some spaces in my diary, I Hospital decided it was time to pursue my interest, fuel the Lada and take stock. My long- Abstract standing friend, Dr Yuriy Kuybida from the John Allwood describes a trip in western anaesthetic department at Ternopil’s Ukraine in search of interesting and regional hospital, made the necessary unusual anaesthesia equiopment. contacts, and we headed towards the Key words small town of Zboriv, 35km west of Ukraine, anaesthesia equipment, Ternopil – Yuriy’s home turf. Polynarkon Reference Driving a hard road down Zboriv straddles the main highway linking Allwood J (2008) Medical services in Gereshk, Afghanistan Technic 5(5): 16-19. Ternopil to Lviv, western Ukraine’s largest city. The hospital that we were heading for was originally built in the late 1800s as Figure 1: Drager portable anaesthesia apparatus the town hall. Yuriy explained that over the years it had also served as the local even involves occasional neurosurgery jail. The last rogue had waved incarcera- work among its 1200 annual operations. tion goodbye back in the 1950s, when the The hospital boasts a busy obstetrics building was converted and became the wing, located within the old prison cells. local hospital. Eventually, we were ushered into the second floor theatre / ITU department of Zboriv the hospital, where the tour concluded. Meting up with Dr Volodymyr Gotsa, The concept of intensive care in small head of anaesthesia, we started a tour town Ukraine is little more than the of the hospital. We walked down creaky provision of a separate room staffed but spotlessly clean corridors while with a dedicated nurse, methodically Volodymyr explained that Zboriv under- checking vital signs. Electrically powered takes quite a mixed caseload, which patient monitoring is not that common,16 TECHNIC | VOLUME 5 | ISSUE 5 | DECEMBER 2008
  • 2. Feature – Ukraine legacy from the time when oscilloscopes were considered all the rage. The nearby theatre staff were busy placing recently autoclaved surgical instru- ments back into their cabinets. Volodymyr drew back a screen revealing two pieces of equipment of significant relevance to the trip. First in line for demonstration was a Polynarkon 2P and an excellent example of an older generation of portable anaesthesia delivery system. The Poly 2 is a simple design, which incorpo- rates bag and bellows plus standard rotometers and an absorption canister. The platform also has interchangeable, though unemployed vapourisers for ether and halothane, plus yolks for two cylinders. In the unlikely event of you Figure 5: Dr Maryana Chorna using an R06Figure 2: A freestanding Polynarkon 2P portable having to change the cylinders aroundanaesthesia delivery system here, oxygen cylinders are coloured were attributed to ether usage, coded blue and nitrous grey. It’s actually manufacturing of the RO9 ceased. The unlikely that even the local clinicians get R06 then underwent extensive much opportunity, as the machine is updating and is now heavily marketed designed to function using room air and as the company’s flagship platform; it cylinders of medical gas are in fact quite is available for 300,000 roubles. The a rarity. Commonly, many of these older RO9 still remains very much in use, Poly 2s, which can be seen, have had provided the ether stash is well their bases removed and bolted onto the hidden. Here is an RO9 variant – the sides of the newer electrically driven RO9H – in use recently for a sub-dural machines, to provide a backup when haemotoma removal in Ternopil. power is down. The one in Figure 2, Our visit to Zboriv became fairly protract- however, is still in its original freestand- ed, and we benefited from someFigure 3: Breeze 2 ventilator ing form. Rubbing shoulders with the traditional Ukrainian hospitality thanks to Polynarkon was the Breeze 2 ventilator, Volodymyr’s drinks cabinet, resulting in us which is a testament to maximum size, staying over night in Zboriv. minimal capability design. From the noises it emits when it spools up for Bukacivtschi duty, you get this feeling that several Next day, we continued, shadowing the hours of nebulised cpap wouldn’t go Dneister river’s meandering course amiss to help it wheeze its way to its towards Bukacivtschi 150km away. The operating optimum – see Figure 3. three-year-old Lada’s robust suspension Unlike the Polynarkons, the breeze is a proved to be more than a match for the bit of a rarity and its purpose confined to road networks’ uncompromising either lengthy post-operative ventilation potholes. As a result of European super- or patients needing respiratory support powers battling out opposing ideologies with humidification. Day-to-day anaesthe- and territorial sovereignty rights, the sia at Zboriv, as in many hospitals in land we navigated through has Ukraine and the Russian Federation, is undergone frequent and bloody national normally undertaken using the RO6 identity changes over the years. This is manufactured by the Krasnograveets (Red underscored by the sheer abundance of Guards) factory in St Petersburg. cemeteries accenting the landscape.Figure 4: An older version of the Krasnograveets Zboriv’s older version is shown in Figure Other occasional signposts to historyR06 for ‘day-to-day anaesthesia’ at Zbrovia 4. Despite its plethora of dials on the front were Red Army memorials, typically the panel, it is really nothing more than a ubiquitous T34 tank – now motionlessand the occasional ECG machine you do ventilator platform, as demonstrated by epitaphs to the defunct Soviet mother-see, has in all probability arrived either Dr Maryana Chorna in Figure 5. land’s lost comrades who fell in thecourtesy of a lengthy transatlantic ride in The RO6 was superseded by the RO9 ‘great patriotic war’.an aid container from the US or Canada, (Figure 6). However, due to several To someone more accustomed to ,or is a veteran Russian-made machine, a instances of machine explosions, which witnessing zealous wheel clampers ply TECHNIC | VOLUME 5 | ISSUE 5 | DECEMBER 2008 17
  • 3. Feature – Ukraine Figure 6: The R09, which superseded the R06 Figure 9: A rare example of an RO-2 respirator medical and surgical caseload. A town on offer here. Alas Myron’s dual role this size, would not normally host a diminished with the appointment of a hospital or even a clinic, and instead dedicated surgeon a short while ago. He would be reliant on the services of a showed us a Polynarkon 4 apparatus, local healthcare provider known as a which normally resides in the small Feldsher. ‘Feldsher’, which means ‘field operating theatre – see Figure 8. This doctor’, was a term imported to the old equipment is used for the hospitals 300 Russian empire from Prussia. Nowadays, annual general anaesthetics. Again, it is it means a multi-skilled health profes- free standing, but smaller and more sional, whose level of expertise and compact than its predecessor the training lies somewhere between that of Polynarkon 2. Although noticeably Figure Outside Bukacivtschi hospital – complete a doctor and nurse. They crew the rural redesigned, its operating capabilities with grazing horses and no parking problems ambulances, attend home births and are almost identical and again air is provide vaccinations, as well as handing used for manual artificial ventilation. out general healthcare advice and Volatile agents are not needed, as a education. Due to the remoteness and rudimentary total intravenous approach, winter conditions, when the snowfall using bolused thiopentone, is consid- that can cut of the town, and the ered adequate for around 90% of mercury can fall below –30 degrees anaesthetics. The remainder are under- celcius, it was deemed prudent to taken using regional techniques. maintain a year-round health facility at Next, in an adjacent room, which Bukacivtschi, serving the local, mainly doubles as the ‘high dependency’ lay a farming community. I was also informed fine example of a very rare RO-2 that during mid-winter when the local Respirator – Figure 9. Developed for road conditions deteriorate, a horse and military use in the 1960s, it comes with Figure 8: A Polynarkon 4, which is normally cart is often pressed into service as the quite an intriguing design history. The used in Bukacivtschi’s small operating theatre local ambulance. (Perhaps we could RO-2 was manufactured from plans persuade the estates management team obtained using cold war industrial their trade, the sight of grazing horses to crew the clamper trucks if the espionage perpetrated against the in front of a hospital provided an inter- ambulance service gets a bit Engstrom company by the KGB. esting backdrop as we entered (Figure overstretched.) Apparently, Engstrom has corroborated 7). Without even a hints of hospital Myron has quite a colourful past I this theory. parking scratchcards or permits, we learnt during our conversation. Until In many ways, it has several character- parked next to a group of medics from recently, not only was he responsible for istics comparable with that of the old nearby Roghatyn who were undertaking administering the patients anaesthetic, Bease pulmoflator, except with a some outreach rounds. We were greeted but also looked after the surgery side of graduated plastic water funnel stuck on by Dr Zinoviy Kuschinsky and Dr Myron things too, once the patient was uncon- its side, with which the user visually Poyasnyk, the hospital’s respective chief scious. Such enthusiastic multi-skilling confirms inflation pressure. executive and chief anaesthetist. They would raise many a directorate In theory, you can control volume and led us on a we tour through the 35- manager’s eyebrow with interest at the pressure by manipulating the knobs, bedded hospital, which has both a cost and manpower saving possibilities dials and bellows screw. In practice,18 TECHNIC | VOLUME 5 | ISSUE 5 | DECEMBER 2008
  • 4. Feature – Ukraine nationally rated around 1960. It was one of the first medical and positive pressure ventilators manufac- nursing college for tured after the polio epidemics of the a long-anticipated 1950s. This machine appears to have its meeting with its roots in France, with the ID plates at director, Dr the rear indicating it had been manufac- Lubomir Bilic. tured by the R Pesty company in Paris. Through Dr Bilic’s How it came to be in Ukraine was a craft, care, dedica- complete mystery to everyone. tion and So all good things must come to an unbounded faith in end. After our fill of more first class a competence- hospitality and some lengthy dialogue based educational in the faculty dining room with Dr Bilic, regime, he has came the moment to part company. transformed the Time was pressing as I had a class ofFigure 10: A class of students in one of Ukraine’s finest training institution into one students to take at the medicalesablishments in Chortkiv of the finest academy back in Ternopil. We transited training establish- the relatively pot hole free M14 for thehowever, most of these are in need of ments in Ukraine. last stretch to Ternopil. Two hours laterrepair and such fine control would be an The colleges establishment of around with class over and the chalk almostexercise in futility. Its functioning param- 1200 students, and when we were there exhausted as I was, there was nothingeters are defined by what still works the atmosphere was fairly hushed else left to do except grab some welland it is pretty much limited to because many of the students were in earned cold ones with a few of theproviding airway support during resusci- the final stages of cramming for students. With the sun setting, a beer intation, as a kind of one size fits all large impending examinations. Chortkiv has a hand and some good company, a greatmechanical ambu bag. wide training remit; pharmacists and way to finally take the hard roads dental technicians also receive their chequered flag.Chortkiv tuition there.After another local night stop we were The college boasts its own radio Thanksback on the road zigzagging with more station and a well known English I would like to express my gratitude toroad-induced bump and grind on the language department where I was all my friends and colleagues in Ukraine,longest leg of our trip towards the warmly received by Ivanna Zakharchuk for the courtesy and hospitality shownsmall town of Chortkiv. This is another and her team. Ivanna has authored throughout my trip. We are now settingtown whose recent landmarks are Ukraine’s main medical English up a new project in Chortkiv, and aredominated by World War Two. The language textbook and many of the well underway with an extensivelocality was an epicentre for the students’ timetables now include laryngeal mask trial at the regionalHolocaust and later in 1944 was on the English language studies. hospital in Ternopil using both conven-frontline of some heavy fighting The concluding events of our tional and the new iGels courtesy ofbetween the retreating Germans and walkabout at Chortkiv saw us gravitat- Intersurgical UK. Ukraine is nowadvancing Soviet tank armies. After ing towards the surgical training room manufacturing very good home-grownmaking several unintended circuits of and a ‘face to face’ with the headline ventilator and monitoring equipment,the town, we eventually found its act of our three-day tour. Standing which is not surprising given its global proud amongt all the other training pedigree and reputation in the worlds of paraphernalia, operating table and science and aviation. instruments (which were also of great interest) stood an absolute showstop- Further reading per of a device (Figure 11). It is still If you found this article interesting used to train students about the princi- then you may be interested in a more ples of mechanical ventilation. in-depth and comprehensive review of Unfortunately, even Yuriy was a bit anaesthesia delivery in Ukraine that I sketchy over its history, although he did wrote: ‘A Toast to Morton and his mention it was in use in a regional narcosis’, which appeared in the hospital many years ago, before being October 2002 issue of Technic. redeployed to Chortkiv. It looked as A more extensive selection of images though it had been shipped straight which interested readers are welcomed from a Pinewood film set after Baron to browse can be found at my image Frankenstein had finished using it to website:Figure 11: An Engstrom positive pressure reanimated his monster. This machine www.flickr.com/photos/johnallwood/sets/machine, now used for training students is in fact an old Engstrom 150, built 72157601139419065/ CODP TECHNIC | VOLUME 5 | ISSUE 5 | DECEMBER 2008 19