On the Medical Frontlines of the War in Ukraine – Dr. Oleg Turkot, Assistant Professor of Anesthesiology and Critical Care Medicine at Johns Hopkins Hospital

Shiv Gaglani: Hi, I'm Shiv Gaglani. Today we're going to take a look at how medical needs are being met in Ukraine in the midst of the war. Our guide is Dr. Oleg Turkot, a Ukrainian American who is currently an obstetric anesthesiologist and an Assistant Professor of Anesthesiology and Critical Care Medicine at my alma mater, Johns Hopkins Hospital. Dr. Turkot has worked in Ukraine for many years, and as the war rages, he's been coordinating resources and treating patients so he's in a position to help us understand what is happening throughout the country, medically speaking. He's also on the board of directors at Kybele, an organization that creates healthcare partnerships across borders to improve childbirth safety, and he's a graduate of Ternopil National Medical Universitywhere we have many learners learning by Osmosis. So, Dr. Turkot, thanks for taking the time to be with us today.

Dr. Oleg Turkot: Shiv, thank you so much for having me, it's a real pleasure to be able to talk about some of the work that we're doing and our fantastic partners all over Ukraine.

Shiv Gaglani: Totally. So let's get started by learning first about you personally. Can you give us highlights of your bio, what got you interested in medicine and then specifically, anesthesiology?

Dr. Oleg Turkot: Of course, I was born in Ukraine, and we emigrated to the U.S. in 1994. I returned to Ukraine and in 2004, I got to be a part of their first Orange Revolution, which really changed the way I viewed my responsibility to the country. I graduated high school there, went to medical school there and got married. There was a lot of promise in the country at that time, but I did not see as many opportunities, so I returned to the U.S. Here, I did my residency, then my fellowship, I stayed on as an assistant professor with Hopkins and recently completed one more fellowship in chronic pain medicine. 

One of the things that I would see -- when I would compare the way that we were educated in Ukraine to the way that we're educated in the U.S. -- is here, learners are a lot more active. It's a lot less book memorization, it's a lot more taking care of patients and problem solving. Back in 2016, I had the opportunity to join a medical mission to go to the Balkans. We worked in Serbia, Bosnia, Macedonia, and the whole time I was talking with my mentor at the time, saying, “You know, this place looks exactly like my hometown. These people look exactly the same. The same issues that we were dealing with when I was going through my medical school…those are the issues that I'm seeing here today.” And he challenged me to get involved and start working on developing a project for Ukraine. 

In 2018, we had our first meetings, our inaugural mission, and since then, we've expanded all over the country. We founded the Modern Obstetric Practice podcast that we do in Ukraine for obstetricians to help improve their care, because obstetric anesthesiologists can't really do anything unless our partners are on board, and then we provide an underground training, including assisting them with development of national protocols. We were really happy with that mission. 

We had big plans. We were just starting a difficult airway school, and then the War happens, and war brings out, I think, the real nature of a lot of people for us. After the stress and fear subsided, we realized that we made commitments that we're not going to be able to step back from. I remember on the 28th of February, writing a mass email to all of our partners saying that, “No matter what happens, we're here for you and we're going to continue to make it better, to the best of our abilities.” That's been kind of the modus operandi the entire time since then. It's been one of the most rewarding things I've done in my life. As far as why I would become an anesthesiologist, because I think that we can function in many places, and if I look back at it now, I became an anesthesiologist to be able to do this specific type of work.

Shiv Gaglani: Well, it's incredible. I know our audience has obviously been following the news quite a bit about what's been happening in Ukraine and we have gotten really involved in the Osmosis and Elsevier side as much as possible helping the thousands of people we know who learn by Osmosis there. But you've been on the ground. You actually went to Ukraine earlier this year, right after the war started, and you're recording this a couple of days before you're about to go back. Can you talk to us a bit about what it was like, in the early days of the war, treating patients? Any memorable moments? And then what it's like now, several months later?

Dr. Oleg Turkot: The war has gone in phases. So initially, everybody's shocked, nobody understood what in the world was going to happen. When I was crossing the border, it was when the Russians first shelled the nuclear power plants. I remember being in the car, thinking about the fact that if this thing explodes, likely the areas that we're going to be going are going to be unsafe and then thinking back to the fact that well, we made commitments and also if it explodes, that anywhere in Poland and Eastern Europe probably is going to be also reasonably unsafe. So, we decided to move forward. 

Initially, there was a bit of community-based organization, meaning every single person was trying to figure out ‘how do we help.’ The pathways that existed were not designed to supply this large amount of medical training, this large amount of medical aid, or all the other things that were missing. We initially started with helping paramedics have access to tourniquets, because the Russians had shot at multiple ambulances and the paramedics were concerned not only for the safety of the patients who they were going to be out taking care of, but also their own safety and we were able to donate large amounts of that sort of equipment. 

Now the situation has changed. There's a lot more equipment on the ground, there's a lot more organization, at the both government and local level, to be able to receive aid. There's also a significant need for training. So often, equipment is easier to provide than to make sure everybody can use every piece of equipment, the best way that they can, and to really improve patient outcomes. That's why the upcoming mission is a training-focused initially. There's plenty of equipment and I'm very grateful to all of our partners who helped make it possible. But in addition to that, we want to make sure that if a hospital receives a Butterfly ultrasound, they're able to use it for a little bit more than just IV access…that they're able to have a development plan to bring in transthoracic echo from an anesthesiologist, to be able to do more nerve blocks, and to be able to expand their skills and train the next steps. I love the train-the-trainer model, and that's been one of the big ways that we've built out the program. So, I'm eternally indebted to all the local champions who work tirelessly, even if I'm here to continue to teach their peers, their colleagues, and future medical students.

Shiv Gaglani: Absolutely. This is a theme that's come up with the Raise the Line podcast ever since we started. We began this podcast at the beginning of COVID when the whole concept was, how do we not just flatten the curve and educate the public to socially distance to wear masks, et cetera, et cetera - but how do we strengthen the healthcare system which has been overwhelmed even in very developed, relatively stable countries like the U.S.? 

Over many years, you have experienced working in less-resourced settings and then now war-torn settings. The Medical Secretary of Doctors Without Borders was on the podcast recently talking about capacity improvements in war-torn countries or lower- and middle-income countries. So this ability for private companies like Butterfly Network, which has donated over two dozen mobile ultrasounds, is really critical but the question is, how does it also scale and I think the train-the-trainer model is exactly why I think you're going to Ukraine. So, can you tell us about the relationship with Butterfly and how it got started and how you can imagine scaling it, in addition to training people on the ground?

Dr. Oleg Turkot: So, in probably the most millennial way, it all started with a couple of tweets. I was leaving on the second of March, and when I looked to order Butterflies, it would take a couple of weeks for me to get any sizable amount of equipment. So I was fortunate to have my twitter friends and reached out to several of them. Emily Sharpe, who was very active in the Society of OB Anesthesia, put a blast out through Twitter to see who can donate a probe or send it over in like a day. The response was amazing. I think we had five probes in less than twenty-four hours. They were in our hands and we were able to travel with them. 

From there, we also were reached out to by Butterfly and they offered to help support the project. They sent additional probes over to us and in addition to that they helped with fixing some of the difficulties a lot of the Ukrainian hospitals have. So right now, they're working on a Ukrainian translation of the app, so that people can actually read what is written and have a better utilization of that equipment. They also have waived subscription fees for donated ultrasounds. That ends up being a significant part of their revenue model, but I think they feel passionate about giving access to people to the appropriate equipment, which is very generous of them. Finally, their price point and capacity is such that, overall, it's reasonably affordable. 

We also donated a couple of full-size, obstetric ultrasounds that were many tens of thousands of dollars. If you're looking at something that can be two to three thousand dollars, that can be deployed readily, and is portable, that really helps. One of the most recent developments in the past couple months has been that physicians need to move. If you have an ultrasound that weighs fifty, sixty pounds, lugging that as you're fleeing from a rocket attack or a shelling ends up not really being your best priority, versus something that you have on your belt and all of a sudden, you're in a basement and you want to assess a child, you can do it. It also brings in interesting capacity. For example, the power grid was systematically attacked in many parts of the country, and when you lose electricity, you can no longer do a CT scan, you can no longer do anything. Heck, even the batteries on the large ultrasounds that we have, those run out relatively quickly.  Here you have the capacity of charging a device from a power bank. You're able to run your generator for only a few hours, and all of a sudden, you're able to get a lot of diagnostic information. I think that the tech revolution that's really happened with mobile devices like this has really improved the quality of care. 

For example, since the war started, we started six brand new regional anesthesia departments. The only thing that would be holding them back before is the lack of equipment, and for a very low price of a couple of thousand dollars, we give them the equipment and all of a sudden care gets better. In addition to it, because we're training local champions, they're able to tell other people about this equipment. So in low and middle income countries, often, income isn't evenly distributed and if you have parts of the population who can afford an iPhone, can afford a nice meal, they can also afford to get themselves the sort of equipment that really makes their life easier.

Shiv Gaglani: Yeah, that makes a lot of sense. I'm really glad to hear about the relationship and how it scaled. I'm curious -- just going very personal, if you don't mind -- what are some of the most memorable moments of providing care on the ground that you can think of? And a follow up question is that you have a very interesting background, being American, being Ukrainian, kind of seamlessly going between the two institutions, training in med school there, but then coming over and now working at Hopkins, in Baltimore, which I'm very familiar with. We worked with a lot of Syrian medical students during that war and learned that there is massive brain drain, right? Tons of people leave because everyone wants a stable life. It's Maslow's Hierarchy of Needs. What's the situation in Ukraine among the Ukrainian medical students, nursing, etc.? Do you feel like it's a brain drain, or do you feel like more people have returned and are providing care? And how do you think the Ukrainian health system will evolve as a result of this?

Dr. Oleg Turkot: The Ukrainian health system is very different in its fundamental structure from the U.S. Here, we often have such a huge shortage of physicians that we're working really hard to find anybody who can fill those roles. In Ukraine, they'll often have a glut of physicians. Their medical schools are very large, so they're able to process a large amount of people and train them reasonably well. A lot of people leave, and that's very natural whenever you have a war, but a lot more people stay.  Those are the people that'll end up building the country, they'll end up improving the healthcare system. 

Most of the places that we have visited do not have a shortage of physicians as much as a shortage of equipment, a shortage of training, a shortage of understanding how they can be the most efficient with the resources that they have, and those sorts of things are actually a bit easier to fix. Some of the work that we did at Hopkins…we were working to start the first residency program in Sierra Leone, to give the country some anesthesiologists. The country has one anesthesiologist who lives there full time, and often he'll go back home to Nigeria and there will be times that there isn't a board certified anesthesiologist in the country. So, building something in that setting is so much more difficult than, for example, providing additional training to an adequate amount of specialists. 

I think the Ukrainian medical system will change. It has to change. I think that they will have to be more resource-conscious because the war has made our COVID shortages really look like nothing. The classic example is, in Ukraine, their main manufacturing of opioids is made in Kharkiv in eastern Ukraine, which is a city that probably right now is actually being shelled. Your ability to run a factory, and to bring all those products to an entire country is very limited. So all of a sudden, opioid free techniques become extraordinarily important. 

I think that the other part that I really appreciate is the international support. The fact that a lot of the Ukrainian hospitals can now have, for example, access to Up to Date, access to medical journals, access to podcasts that are free…it really takes away a lot of the paywalls and that ends up being extraordinarily important. Often, people don't have the ability to look at the most recent literature and then they do their best, but without the understanding of really what else they can be doing to improve.

Shiv Gaglani: Absolutely, that's fascinating. Thanks for explaining that. I mean, the surplus of doctors, but the lack of training or equipment makes a lot of sense, and really, I think our team will be glad to hear that that's the case. I remember in March, every day we had a task force meeting about how we could help our Ukrainian learners. Fortunately, we joined Elsevier four months before the war in Ukraine, so now had a lot more resources. Elsevier itself donated a million dollars to UNICEF Ukraine. Then led by our President of Health Markets, Jan Herzhoff, and our Head of Customer Success, Lindsey Smith, we also donated tens of thousands of subscriptions to Grey's Anatomy, Netters, Clinical Key, Osmosis, Complete Anatomy and a whole bunch of things, so it's good to hear that the training was well received. To the other part of the question, what are some personal stories, if you're willing to share? Things that maybe come to mind from being on the ground there?

Dr. Oleg Turkot: I think one of the stories that probably touched me the most is I had a friend of mine, a Ukrainian anesthesiologist, who was working in Britain, come back to Ukraine, and his mission was not just to work in a medical capacity, but instead to actually go and fight. He was in eastern Ukraine, and he was the medic of his special forces unit. He received a shrapnel wound going through both of his arms in that process. Now, for an anesthesiologist to lose arm function, it's probably one of the most devastating things that can happen to us because we're so procedurally-based. I heard about it and I remember reaching out to him. He picks up the phone only about twenty minutes after I called him and says, "I'm really sorry, but I'm getting surgery right now. I'll have to call you back" 

Shiv Gaglani: Oh my God, wow. 

Dr. Oleg Turkot: As soon as he calls me back, we catch up, and he says “You know, I've regained function in both of my hands. So, what I'm going to do is go off and inspect the hospital and see what things I can do to teach them, see where we can find some improvements and I'll relay back some extra information so that you can be in touch with them and make that system better.” 

I haven't seen that much real heroism. We talk about heroism in medicine, we talk about growing up and going into the COVID pandemic, dealing with difficult situations. But even with that, I think he's really taken it to a brand-new level. So that's been arguably one of the most touching stories for me. He's actually going to be helping us train with some of the local physicians for difficult airways in about four days, and we're excited to report that his arms are back to normal function, and he's gonna be helping develop the mission.

Shiv Gaglani: That's amazing. It really puts things into perspective and certainly for the people in Ukraine and the people like yourself who flew in to help with the crisis, it's one thing after another… the COVID pandemic, and then this war, both of which seem to be endemic right now. Tell us a bit more about Kybele and why you became involved with them and the work you're doing with them.

Dr. Oleg Turkot: Of course. Kybele was initially founded back in 2000. They were founded when one of our leaders traveled to Turkey and noticed the difference in care for women during the laboring process. She helped write the first textbook for obstetric anesthesia in Turkish, and from there, they started their work in Ghana, they did a huge project in Georgia, Armenia, we're currently active in Bolivia, the entire Balkan region, Ukraine, and Mongolia. 

In the way that we assess societies, I think one of the biggest telling signs of development is how well do we treat women and children? And if you think about it, the birthing process is a really vulnerable process for women. So, anything that we could do to make that better is really a worthwhile endeavor. From there, the opportunity to participate in trips during residency was really paramount in getting me involved and really helping expand the idea that you can be a practicing anesthesiologist, and also do really helpful work worldwide. Often doctors are busy, and it's really hard to consider the idea that you'll take ten, fifteen, twenty days off until a bit later in your career. For me, this is where it all started, and where I see it continuing over the years.

Shiv Gaglani: I definitely would love to put that in the show notes and get people to look at both Butterfly as well as Kybele -- both very worthy organizations to partner with. I love that you refer to how we treat the vulnerable populations. We're recording this today on August 15, which happens to be Indian Independence Day. This quote from Mahatma Gandhi (or ostensibly from him) has been circulating, which is, "A civilization is measured by how it treats its weakest members." And so certainly, supporting women and children, especially in lower income countries, or countries that are war torn like Ukraine, is really critical. 

I know we're coming up on time and you're in scrubs as we're recording this, so I want to be respectful to your patients and you. I had two other questions. The first is how can our audience get involved? How can they help? Obviously, there was an outpouring of support in March, April, May. Seems like things have calmed down a bit since then, what do you guys need most?

Dr. Oleg Turkot: Overall, whenever we consider these things, it's always a marathon and not a sprint. In the initial phases, you hear about the war, you hear about horrible things that happen, and people want to donate money, donate their time, and come over and help out. Now, since that interest is slowly starting to wane, I think the most important thing is to continue to be supportive, to continue to support organizations that are doing the work on the ground because this is going to have to continue for years. A lot of Ukrainians are displaced in Europe so if you're able, reach out and help them. It's very helpful for people who are, for example, on the frontlines either in the hospitals in the trenches, or just living in Ukraine and not really able to get out. We would always appreciate donations to Kybele, and if you're so inclined, we would make sure that the funds would be used to help take care of the most vulnerable people in Ukraine.

Shiv Gaglani: We’ll definitely put that in the show notes as well. My last question for you -- and this may actually be a personal question because, as I mentioned, I'm still a medical student at Hopkins…I just have taken a leave for now nearly a decade to start and grow Osmosis, so you could actually be my attending in a couple of years for anesthesiology for OBGYN or whichever service we're on. What advice would you give me and other healthcare professionals about meeting the challenges of the COVID pandemic, the war in Ukraine, the healthcare system in general moving forward?

Dr. Oleg Turkot: For many years, we've dealt with many difficulties and I think that modeling the resilience that you see in people who went through difficult situations is one of the best ways to be prepared. That being said, nothing prepares you for every single situation. So, this is where a strong base of knowledge and also a human side of compassion really makes people be fantastic physicians.

Shiv Gaglani: That's incredible advice, and certainly a good reminder for those listening out there. Is there anything else that you'd like our audience to know about you, about Butterfly, Kybele, Ukraine, or anything else that you'd like to leave them with?

Dr. Oleg Turkot: I think to close, the most important thing to remember is, these sorts of crises will happen in the world, and if you feel the call to do something -- no matter how improbable and difficult it appears -- just trying your best and working on it can have you reach incredible success. So, never sell yourself short, and please continue to try and work to help people.

Shiv Gaglani: Well, Dr. Turkot, thank you so much, not only for taking the time to join us on the Raise the Linepodcast, but more importantly, for the work that you're doing on the ground in Ukraine and also even in Baltimore and Hopkins in training the next generation of healthcare providers and providing direct patient care.

Dr. Oleg Turkot: Thank you so much. It's been a real pleasure talking.

Shiv Gaglani: With that, I'm Shiv Gaglani. Thank you to our audience for checking out today's show, and remember to do your part to Raise the Line and strengthen the healthcare system. We're all in this together. Take care.