Podcast

Meaning in medicine: Frontline physicians in Ukraine

CMA

The strain of working in a health system on the brink – not to mention two years of a pandemic – can erode the sense of meaning that motivates so many physicians. But two emergency doctors, Anthony Fong in Vancouver and Daniel Kollek in Hamilton, found inspiration by going towards, rather than away, from crisis on a volunteer medical mission in Ukraine.

“We provided emergency care in a setting that was really needed... And we didn't have all the bells and whistles you might find in an emerg (ED) in downtown Vancouver. But it doesn't matter. All that matters in that case, in that situation, is that you're communicating as a team and doing as much as you can.”
– Dr. Anthony Fong, Vancouver Coastal Health

“It certainly charged my batteries. It reminded me that what I’m doing is helping people in a meaningful way. It also reminded me that we are phenomenally fortunate, not only because we're away from war, but because of all the resources we have.”
– Dr. Daniel Kollek, Centre for Excellence in Emergency Preparedness

In this episode, host Dr. Caroline Gérin‑Lajoie speaks to the two physicians about the conditions they faced at the Ukraine/Poland border, the care they provided and the impact of their experiences on their sense of purpose in medicine.

This episode is available in English only.

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Meaning in medicine: Frontline physicians in Ukraine

Dr. Caroline Gérin-Lajoie: Welcome to Sound Mind, a podcast about physician wellness and medical culture. I'm your host, Dr. Caroline Gérin-Lajoie. Russia's invasion of Ukraine has triggered many emotions and reactions in the medical community. The invasion has created more than 4.5 million refugees so far. More than half of them have crossed into neighboring Poland in search of shelter and safety.

Dr. Caroline Gérin-Lajoie: On this episode, we're going to explore why two Canadian doctors, one from Vancouver, the other from Hamilton, volunteered to assist at one of those border crossings. Dr. Anthony Fong is an emergency physician and clinical assistant professor at the University of British Columbia. Dr. Daniel Kollek is also an emergency physician and assistant clinical professor of emergency medicine at McMaster University. Both men traveled to Ukraine as part of Canadian Medical Assistance Teams or CMAT. It provides international humanitarian assistance and is run by volunteers and funded by donors. Drs. Fong and Kollek recently returned from Ukraine. Thank you both so much for joining us.

Dr. Daniel Kollek: All right, my pleasure.

Dr. Anthony Fong: It's great to be with you. Thank you so much, Caroline.

Dr. Caroline Gérin-Lajoie: Anthony, this was not first time volunteering for an international assistance mission, but what made you decide to go to a war zone?

Dr. Anthony Fong: Caroline, I didn't really expect to be deployed at first, because as you alluded to CMAT has lots of experience in disaster zones in terms of natural disasters, but this is the first time they were really going as a deployment to a war zone. And so when I first heard about the deployment, I was actually in Mexico on a vacation and I got a message from the executive director saying, "Hey guys, there's a call out for this." And I didn't seriously think it would actually happen, but I was just interested because it was all over the news at that point in time.

Dr. Anthony Fong: And then when I returned, basically we're on standby which is a state in disaster deployment where you set everything side, you ask around to get people to take your shifts just in case you have to go. And then once you get the green light to go, then you usually have to deploy within 48 hours. And so I was ready this whole time or I was getting ready. And then once that green light went, I was like, "I guess it's happening." And you just pick up your stuff and leave. And so it wasn't planned. It was just a spur of the moment decision.

Dr. Caroline Gérin-Lajoie: Daniel, you have a lot of experience in disaster response through your role as chair of the Canadian Association of Emergency Physicians Disaster Committee, but this was your first experience with an international crisis. Tell us how the decision to go to Ukraine came about for you.

Dr. Daniel Kollek: Well, there are two sides to this. One is that my experience and knowledge base have always been on the receiving end at hospitals and so on because that's what emergency physicians do. My hidden guilty secret was I had never deployed as an away team. So part of this was for myself I really felt that I needed to make sure I understood and experienced it myself, but on a much deeper level, I was watching what was going on and my family escaped World War II in Europe, and I really can't expect anybody else to stand up and help if I'm not willing to do it myself. And at the time people didn't. So I think I have an obligation to stand up and help others now.

Dr. Caroline Gérin-Lajoie: You both ended up at the same location in Ukraine, and we will walk through the story of how you got there. But first, did you know each other before this mission?

Dr. Anthony Fong: Nope. Nope. First time we're meeting.

Dr. Daniel Kollek: We met as roommates. When we landed, the first nights we crashed together.

Dr. Caroline Gérin-Lajoie: And there was an instant bond and connection.

Dr. Anthony Fong: Totally. We were both coming from opposite sides of the country, but I think it was immediately apparent that we're on the same page in terms of we're both there to do good and we both have some experience in terms of disaster medicine.

Dr. Daniel Kollek: I think the fact that there's a common mission creates a common kinship right away, because we all really want to do the same thing and we're motivated to work together.

Dr. Caroline Gérin-Lajoie: Anthony, can you walk us through the journey of getting to that Poland-Ukraine border? What was that like?

Dr. Anthony Fong: The journey Caroline was all but smooth. I think the minute we landed our first task really as a medical deployment was to find the most appropriate site with the highest need for medical care for refugees. So we were at first operating off basically a tip that I had gotten from a Quebec doctor who had set up clinic by a border site called Hrebenne in Poland. It's on the Polish side just meters away from the border. And this a physician, Dr. Auger, had set up a clinic and had been operating it almost single handedly for two weeks before we arrived.

Dr. Anthony Fong: And so the night before I left for Poland, I was talking to him on Facebook. I didn't know this gentleman beforehand. I just basically saw him on the news. And I was like, "How are things going there?" And he responded, "I need help. Please come and lend a hand because after I leave there's nobody. It's just me." And he had one other colleague, but that colleague had been away for a couple days in a row. And so our first task was to assess that site. And that site turned out to be quite a mishmash of different NGOs competing for the space. And it ended up being quite an adventure trying to negotiate between different players on who was going to do what and who was best suited to run a clinic there.

Dr. Anthony Fong: And so we ended up deciding that wasn't the site to set up. And so we had to choose another site. So that delayed us by a couple days. We then got hooked up with Polish Medical Mission, which is this NGO run out of Warsaw. And through them, we found another site on the Ukraine side called Krakovets and we ended up setting up there on the Ukraine side.

Dr. Daniel Kollek: The setup there was an interesting experience because we wanted to be sure we're doing something that is meaningful and that is helpful. So a team of three of us went out there based on an exploratory move, and we realized that what's happening there is there had been an ambulance put there with some paramedic students, but they were just basically parked outside of the flow of people and they'd had six fatalities in the prior week to 10 days. So what we realized was that there's room for us to position ourselves literally in the flow of the refugees so nobody could get by without actually seeing them. Not obstructive, but we were just there.

Dr. Daniel Kollek: And that worked beautifully, because as the buses came by, we could see every coming in. We knew we could spot somebody who was sick and they could see us, because before if they didn't know where the ambulance was, they wouldn't know to go for help. And if the ambulance didn't know there was a problem, they wouldn't know how to connect. So we actually put ourselves in the stream and that worked beautifully.

Dr. Caroline Gérin-Lajoie: Daniel, can you describe a little bit more about the scene at the medical setup?

Dr. Daniel Kollek: Sure. Buses would pull up with refugees from a variety of places. The majority we saw were from Kharkiv and from Mariupol. They would unload people at the bottom of this long ramp that they would walk up to and they would come into a tent. It was a large white rectangular tent. And as they were coming in, there would be announcements made on a loud speaker telling them that, "You're here. You can stay warm. You can charge your phones." Because everybody had phones, that's how they stayed in touch with each other as the families were separated.

Dr. Daniel Kollek: There was food, there was coffee, tea and so on. And so they would come on in, they would warm themselves up. They would stop for a while. As they came in, we were right at the entrance so they could see. We had signs up in Ukrainian saying that it was a free medical clinic. And so they would come to us if they had concerns. And if we saw someone who looked distressed, then we could reach out to them.

Dr. Daniel Kollek: They would spend a bit of time in the tent and then they would move on from there to another staging area just before crossing the border, which they would cross on foot. And then at the other side once they got across, there would be buses picking them up and taking them to further stations in Poland. And the nature of this is that people moved in buses. There would be a busload would arrive, a busload would get picked up the other end and then they would shift through as a massive people. And then the next bus would arrive and fill the tent again.

Dr. Caroline Gérin-Lajoie: Were you able to speak the language?

Dr. Anthony Fong: I can take that one. So the quick answer is no. So CMAT had provided us or as part of our team, we had Natalia Halych who is Ukrainian-Canadian and was able to speak Ukrainian and Russian and English. So she acted as our interpreter for the first couple days. And then after that, she had to leave early because she had commitments back in Toronto. And after that we had a combination of different actors, different very generous volunteers from various places almost randomly offered to help us interpret. Two of these interpreters were from the Jewish Messianic Congregation of Kiev. And they had set up a tent just across the street from our large white welcome tent and our medical clinic.

Dr. Anthony Fong: And they wandered by one day while Natalia Halych was interpreting for us and they asked, "Hey, do you need help?" And we soon became pretty tight. They spent a couple days with us and these are people who have jobs. During the week they have to go back to Lviv and work. And then on weekends they join us and they act as interpreters. And we also had interpreter from another partner NGO, Katia Trusova, who came from Texas. She's Ukrainian, but she's living in Texas and she joined us for a few days as well.

Dr. Anthony Fong: And her story is very interesting. Her mother is actually from Kherson, which is a town in the southern part of Ukraine. And her mother at that point in time was actually trapped in that area of Ukraine. And so Katia came to Ukraine in order to help people in general, but her heart of course, was in her hometown hoping that her mom would get out.

Dr. Caroline Gérin-Lajoie: Daniel, can you talk to us about some of the medical cases that you were seeing?

Dr. Daniel Kollek: Sure. The vast majority of what we saw was primary care. In the time I was there I only saw one trauma patient directly related to warfare. That was a patient who had shrapnel wounds that were at this point two days old. And he really just wanted a dressing change because he had to keep going. And as we'd mentioned earlier, their goal is to get to Poland. It's not to see me. So as long as he was safe, which he was, we redressed that and had him go for more definitive care in Poland.

Dr. Daniel Kollek: Most of what I saw were things like headache, nausea, vomiting, people who were on buses for 30 hours were worse for the wear. We had a lot of people who had underlying illnesses that were not being treated, primarily hypertension, where they ran out of meds. Some cardiac patients who'd had some chest pain and a lot of anxiety, which is quite reasonable. And I remember having some discussions with people who saw that their blood pressure was higher than usual and they were worried. And I would tell them, "This is not a normal situation. For you to have a normal blood pressure now would be worrisome." The fact that you have a bit of an elevated blood pressure is probably pretty adaptive and just to reassure them because they had very solid reasons to be anxious.

Dr. Caroline Gérin-Lajoie: How well resourced were you to help and do your work?

Dr. Daniel Kollek: I think we were quite well resourced and we were adaptive. When it came to delivering the basics of primary care, again, dressings, assessment, basic meds, antibiotics, antinauseants, all the things we needed, we had what we needed. Where we sometimes would be challenged is patients would show up with their last three tablets for some sort of hypertension or cardiovascular issue. And a lot of them were on these combined medications. So we would figure out the Cyrillic and see this is a beta blocker and this is something else. And we would come up to the closest approximation we could get and give them at least a day or two supplies so they could manage to get into Poland and get their original drug. But we really were I found quite well supplied. We weren't designed or intended to treat acute trauma. So from that viewpoint, we didn't need that.

Dr. Caroline Gérin-Lajoie: During this experience, were either of you ever concerned for your own safety?

Dr. Anthony Fong: It's always at the back of your mind. So from the very first couple of days we installed apps on our phones that were air raid alarm apps, that were in the Cyrillic script. And basically the app would simulate an air siren whenever an air siren actually went off in the Lviv oblast region of Ukraine. And I remember the very first time I heard an air siren we were in our guest house in, I think it was Tomaszów. And it was just jarring. It was really a wake up call literally, because it happened in the middle of the night. It was like 3:30 AM as they tend to happen. And it really made real what was potentially a risk. After a while we would just get used to it because these air raid sirens they just went off on a nightly basis, usually between 3:30 AM and 5:00 AM.

Dr. Anthony Fong: And usually they were false alarms that were canceled very quickly, but sometimes the alarm would go off and it wouldn't be canceled and you would just be waiting a couple hours just for something to happen. And we would just stay awake. I was on the night shift for three nights in a row and we would just stay awake. We had the option of sleeping because sometimes it wasn't that busy, but sometimes you just can't sleep through something like that. So it's always in the back of your mind that something could happen even though probably we're okay. Nothing comes without a little bit of risk in the disaster response game.

Dr. Caroline Gérin-Lajoie: The decision to go to Ukraine comes at the end of two long years of the pandemic. How would you gauge your wellness as a physician here in Canada during COVID-19?

Dr. Anthony Fong: Fluctuating wildly. I would say at the very beginning of the pandemic, March 2020, there was almost no other time in my career where I felt like I was needed more that in that first month or two, because there was so much to learn and things were changing all the time. And all the media was pointing towards COVID-19 as a story, as something that in every aspect of society. And so we kind of went through this kind of rollercoaster of emotions.

Dr. Anthony Fong: And sometime last summer I found that I wanted to do something a bit different with my career because it just seemed that there was no end in sight in terms of working in, what I would say, it's pretty difficult conditions having to work masks with a lot of people that you might have not seen the other half of their face ever before. I'm sure lots of people in the healthcare profession can identify with that kind of situation.

Dr. Anthony Fong: So in September of 2021, I decided to pursue journalism. So I signed up for a fellowship at University of Toronto and I cut down my shifts to part-time. So I think the journey to answer that question of what do you find meaningful in your career, I think it's constantly changing and I think it's natural to question that at least every few years if you're doing the same thing for a year. I'm the kind of personality where I've got to change something after a while because I find that just the reward centers of my brain, they stop firing, and my ability to stay in that same sphere doing that same practice, it plateaus.

Dr. Caroline Gérin-Lajoie: What about for you Daniel?

Dr. Daniel Kollek: I'm constantly reminded of the fact that I am an older physician and Anthony is a younger physician, because I had just gone down to halftime before COVID happened. And then of course I found myself at time and a half. We sort of went from at the beginning it wasn't panic, but it was this level of we've got to get things in place and through the Canadian Association of Emergency Physicians and through another group, the Center for Excellence in Emergency Preparedness, we started putting out guidelines once or twice a week on how to organize your emergency department, how to divide into hot zones, cold zones, how to flow people through a first set of at least general orders you can use to assess patients. We were churning out information and so you really don't have time to get panicky if you're exhausted. So you just kept on working at stuff.

Dr. Daniel Kollek: And that to me was my way at least emotionally of coping with what we were seeing, the stuff coming out of Italy, and that was terrifying. And then at least I was worried about bringing anything home. So we would change at work and shower at work. And anyone who felt vaguely unwell were not going near our family. So that was at the beginning. And then as with everything else you acclimatize. And after a while it became, "Ugh, I've got to put a mask on again. And I really cannot see through this face shield and I am sweating like crazy under this gown." And so it became irritating, which is probably a sign of adapting to it.

Dr. Caroline Gérin-Lajoie: On this podcast series we've heard how clerical work or the admin burden of medicine can often erode the sense of meaning physicians derive from taking care of their patients. How is the experience different in Ukraine and Poland?

Dr. Daniel Kollek: It was wonderful in the sense that you could focus on not only what we felt to be important, but what we got into medical school for the first place. Nobody joins medical school with the intent of doing more charting, as you will never see someone saying, "Why are you going to medical school? I just want a chart." That doesn't happen. And what came to mind was there was a period when the emergency physicians in my hospital were also running cardiac arrests before we had a dedicated arrest team. And when the arrest call would go out, suddenly you had total clarity, you had total priorities, "This is the one thing I have to think about." And every other burden was taken away from you.

Dr. Daniel Kollek: And in a way the arrests were some of the most relaxing times as odds it sounds because from that viewpoint, I didn't think about anything else. I'm focused on one task, one task only. And it is the task I trained for as opposed to all the other stuff that exhausts us that we were never trained for and that is constantly changing. Medicine doesn't change anywhere near as fast as the computer systems we have to adapt to deliver the medicine. So I found it liberating not to have to focus that much. We did have to do charting, that's part of the WHO standards, but it was focused on important things and not 10 million demographics that don't really change patient outcome.

Dr. Caroline Gérin-Lajoie: And what about for you, Anthony? Did you find more meaning in the work in Ukraine?

Dr. Anthony Fong: I wouldn't say I found more meaning in the work in Ukraine in terms of EMR as a distraction from your actual work, just by virtue of the fact that when I was working, I was the one that was doing most of the charting and our EMR was as usual. With EMRs I think this norm is that they're not particularly user friendly as a rule, so this one was no exception. But you get a down pat and it becomes less of a distraction.

Dr. Anthony Fong: But I agree with Daniel in terms of when things hit the fan, having that burden of immediate charting removed is a huge weight off my shoulders. And just to know that everyone is communicating with words, looking each other in the eye, and everything I'm saying is being listened to in terms of orders are being given. Orders are being heard. We are asking each other about what you think about this situation. We are getting a consensus about what we should do.

Dr. Anthony Fong: One example comes to mind in the field in Krakovets that I recently wrote about in the news. So one of these cases was a case of a young man, 27-year-old, from Kharkiv who basically his mother presented to our medical clinic at 1:00 AM in tears. And she told us that her was having a seizure in her tent. So one thing you need to know about Krakovets is that there's a tent city set up there. It's a hodgepodge of various NGOs set up offering supports and also families that can't necessarily cross the border immediately. Maybe there are some problems with their documentation or maybe they just think that's the safest place for them to be at that point in time.

Dr. Anthony Fong: So I, one of our most experienced emergency nurses and our interpreter went across the street to this tent. And we entered this tiny circular tent, and we found that there are about a dozen people standing inside and their eyes were all fixated on this one 27-year-old man and he was indeed having a seizure. And we didn't have any of the burdens of charting in the way then. It was just assessment, making a plan together. We had determined that we were going to put him in recovery position. Brandon, one of our experienced nurses, he went to get a wheelchair and we made a plan to evacuate him out of the tent and then get into an ambulance after a quick assessment.

Dr. Anthony Fong: And so we did that and we brought him to the tent. It just so happened he kept on seizing. We couldn't find the problem. It wasn't his blood sugar. We had no lab support. So we needed to call the Ukrainian ambulance. And then afterwards, the ambulance arrived, gave him some injection of benzodiazepines to stop his seizures and they transport him to a hospital. And the closest hospital was in Lviv about 70 kilometers away.

Dr. Anthony Fong: And throughout that whole time, it's not like we were charting everything that we were doing. Everything's just you're scribbling down things on a napkin in terms of vital signs. And you're just talking to each other as a team and that charting stuff can happen later. So I found that experience quite meaningful because we provided emergency care in a setting that was really needed. If we left him in that tent, he probably would've died. And we didn't have all the bells and whistles of what you might find in an urban emergency in downtown Vancouver. But it doesn't matter. All that matters in that case, in that situation is that you're communicating as a team and doing as much as you can.

Dr. Caroline Gérin-Lajoie: Thank you.

Dr. Daniel Kollek: Anthony said something that really resonated with me and that was that we were talking to each other. The communication was person to person and not person to computer to person. There was a moment when I was seeing some patients and I was working with one of another very experienced nurse, Teresa, and I listened to the person's lungs and I was saying out loud that, "There's some crackles here." And she heard it and she's already pulling the meds because she knows what I'm going to do. And she just looked at me and I didn't say anything. I just nodded and that's all. And that level of community is far more complex and far deeper than what we do normally. And it's much more emotionally satisfying.

Dr. Caroline Gérin-Lajoie: So Daniel, now that you're back in Canada, has the experience rejuvenated your sense of meaning or purpose?

Dr. Daniel Kollek: It's certainly charged my batteries. It certainly reminded me of the fact that what I am doing is helping people in a meaningful way. It also gave me a reminder that we are phenomenally fortunate, not only because we're away from war, but because of all the resources we have. So all that context is important. So from that viewpoint, it certainly was rejuvenating.

Dr. Caroline Gérin-Lajoie: And Anthony, given that this was your first experience in a conflict zone, how did it impact you?

Dr. Anthony Fong: Well, I think in this case, I was lucky enough to learn by doing and learn by being thrown into play, so to speak. And I think it gave me a new appreciation for disaster medicine, disaster response and humanitarianism as a whole, as a discipline. And because it does require discipline. You have to have your standards, you have to have a strong code of ethics. And by the way, that code of ethics is in writing. There's the Sphere Guide, which is a guide online that has a very good recommended ethical code that one should follow if you're going to do humanitarian work.

Dr. Anthony Fong: And I think just watching on the ground great examples of that happening and also watching very poor examples of that happening all at the same time, all during one deployment, I think it really struck me as something that's very important to promote in terms of it's a discipline. And lots of people have asked me since they realized that I went to Ukraine and Poland for two weeks, "What can I do to help?" And this experience has changed how I would answer that question, because Caroline over in Poland and Ukraine, there are very well-meaning and some very good effective NGOs on the ground there. But at the same time, we did see a lot of ineffective humanitarianism or even humanitarianism that gets in the way. Examples of people showing up alone without any logistical support. Examples of people taking each other's things.

Dr. Anthony Fong: We had some boxes of our medications stolen. We did not know the purpose of the theft. There were people competing for space to do humanitarian work. And there was just a lack of coordination that we saw there that happens in lots of disaster zones, but it's definitely the first time that I've seen it on such a scale. And so it renews my interest in this field as a whole and gives me a lot of work because I really want to learn as much as I can in the next few months and especially if I decide to go again on a similar deployment or any other disaster response deployment.

Dr. Caroline Gérin-Lajoie: Daniel, what would you say to a physician who may be searching for meaning outside their day-to-day work? Would you recommend this type of experience?

Dr. Daniel Kollek: I'd recommend doing something that you feel has meaning. This type of experience is one example, but I think the same thing could be achieved by working with the homeless. The same thing could be achieved by working with people are otherwise disadvantaged, by working with refugees who come to your community. There are a lot of people who need our help and we are certainly as emergency physicians uniquely qualified to cross across broad swaths of medicine at an intensive primary care level and help a lot of people. You don't have to go halfway across the world to do it.

Dr. Caroline Gérin-Lajoie: Thank you both for sharing your experiences with us and thank you for the important work that you do.

Dr. Daniel Kollek: Thanks Caroline.

Dr. Anthony Fong: Thanks Caroline so much. It's been a pleasure being on your show.

Dr. Caroline Gérin-Lajoie: Dr. Anthony Fong is an emergency physician in Vancouver and Dr. Daniel Kollek is an emergency physician based in Hamilton. Sound Mind is produced by Podcraft Productions. If you're looking for resources, tools, and research on the topics covered today, please visit the CMA Physician Wellness Hub at cma.ca. We'd love to hear what you think of Sound Mind. Please consider giving us a rating or review through your favorite listening platform. I'm Dr. Caroline Gérin-Lajoie, thank you for listening.

Meaning in medicine: Frontline physicians in Ukraine

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Meaning in medicine: Frontline physicians in Ukraine

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Related resources

CMPA podcast: COVID-19 – physician moral distress

Learning from Adverse Events: Fostering a Just Culture of Safety in Canadian Hospitals and Healthcare Institutions

Burnout among health care professionals: A call to explore and address this underrecognized threat to safe, high-quality care

NHS London Leadership Academy

STEPS Forward program

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Meaning in medicine: Frontline physicians in Ukraine