At 5 am on Thursday 24 February Angels consultant Tamara Zabashta called her teammates Lev Prystupiuk and Maria Sheverdina to pass on information she had just received from her best friend in Kyiv.
Russian troops were invading Ukraine. The country was at war.
Maria’s war had in fact started 30 minutes earlier with a call from her daughter, 15-year- old Dasha. In their family home in Kharkiv, Dasha’s room faced onto Belgorod Road and the neighbourhood school less than 50 metres away. Maria could hear the thunder and crash of missiles raining down on Kharkiv’s Piatikhatki district, the explosions illuminating the room. Days later, the school lay in ruins.
Maria and Tamara had arrived in Kremenets the day before, catching an early flight to Lviv and continuing the journey by car to participate in a two-day EMS conference. But by evening, sensing “something in the air”, Maria had decided to leave the conference early and return to her children in Kharkiv.
When Dasha called at 4.30 am, Maria was already at Lviv airport where a flight was due to depart for Kyiv at 7 am. From there she would continue to Kharkiv, 1,000km to the east. Maria says, “It had never seemed so far.”
But by 7 am the airspace over Ukraine had been closed for civilian air traffic. It would take Maria an agonising 41 hours to reach Kharkiv and join Dasha and 10-year-old Varia in the bombshelter underneath their home.
There they would remain trapped for the next 10 days, a sleepless Maria holding her daughters close at night.
Lev was asleep when Tamara’s call came through and at first he didn’t believe her. Then he left his hotel to fill up his car and several jerry cans with fuel. There was already a long line at the petrol station. Next, he checked the supplies of food and water inside the bombshelter at the simulation centre in Poltava, just 100 km southwest of Kharkiv.
Lev was in Poltava with a group of doctors from Armenia who had come to Ukraine for two days of simulation training. Now war had broken out, there were urgent concerns about the Armenian party’s safe return. But by Friday he’d managed to arrange their transfer to Kyiv and their return from there to Armenia via Romania.
Then, traveling to Lviv with his family, Lev made a detour in Kremenets to pick up Tamara and her husband, Franck.
As troops clashed in the streets of Ukraine’s major cities, the team at Angels HQ in Ingelheim, Germany, were grappling with the logistics of getting Tamara and Franck safely across the border with Romania.
Finally offered passage in a car with enough fuel and a driver with the right amount of courage, Tamara and Franck crossed into Romania on foot and spent their first night sleeping on the floor of a hostel near the border. Tamara, who was almost three months pregnant, did her best to stay calm but the news from Kyiv made it impossible to sleep.
Throughout the three weeks they spent in a Bucharest hotel she remained convinced that the war would end at any moment, and that they’d return to Ukraine if not today, then surely tomorrow.
BEFORE THE WAR
When the Angels Initiative was launched in 2016 acute stroke care in Ukraine was almost non-existent – except in Vinnytsia where Professor Sergii Moskovko was chief neurologist at Vinnytsia National Pirogov Medical University. Angels co-founder Jan van der Merwe says, “Once we understood that his hospital alone treated as many patients with acute recanalisation as hospitals in the rest of the country combined, we made it a point to invite ourselves to Prof Moskovko’s hospital to learn from him how to do what seemed impossible.”
Over time they got to know two more innovators who were open to new ways of working – Dmytro Lebedynets, who is now head of the stroke centre at Feofania Clinical Hospital, and his younger brother Pavlo who back then was a neurology resident in Kharkiv. Together with the Lebedynets brothers, Prof Moskovko, and Dr Mykhailo Tonchev and his team from Sklifosofsky Poltava Regional Clinal Hospital, a World Bank funded simulation centre was established at Sklifosofsky Hospital in the city of Poltava in central Ukraine where the first simulation training took place on World Stroke Day in 2018.
By the time Lev woke up in Poltava on the morning the war started, a great deal had changed for stroke patients in Ukraine.
Three years earlier, in 2019, a massive policy change in respect of stroke had occurred in the country’s ministry of health – the result of great diplomacy and patience by Lev and his fellow consultants. Their strategy had been to influence key opinion leaders who had the health minister’s ear. With support from the World Bank and local associations, and the benign influence of Professor Moskovko, they’d achieved what had been unthinkable just a few years earlier.
Over 200 hospitals were now earmarked to become stroke centres, and in the course of 2020 the health ministry acquired 161 CT scanners to be installed at these hospitals.
The new government orders had also updated the protocols for prehospital stroke care.
But policy change cannot succeed without implementation. It was now up to the Angels consultants to provide training to ambulance services and help newly minted stroke teams address knowledge gaps, master the guidelines for acute stroke treatment and optimise their stroke pathway.
Ukrainian schools had meanwhile enthusiastically adopted the FAST Heroes stroke awareness campaign that was launched in 2019. Within six months, 2,258 teachers from over 600 schools in the country had registered with the programme, reaching almost 27,000 elementary school children (the highest enrolment for any country in the world). One of these, an eight-year-old living in Lviv in western Ukraine, was featured in a BBC documentary after her ability to recognise the signs of stroke saved her grandmother’s life.
Lviv was largely unscathed by the war until 18 April when four Russian rockets smashed into the city, killing seven people and injuring at least 11. Further attacks on Lviv’s infrastructure occurred in May, June and October. But the heaviest fighting took place in the south and east of the country, and the migration to the west of stroke physicians whose own hospitals had been destroyed became part of the extraordinary story of stroke in Ukraine’s darkest hour.
DURING THE WAR
The effect of Angels support for implementation of Ukraine’s new stroke policy was exponential. In 2019 the number of stroke patients treated with thrombolysis almost doubled from 480 the previous year to 912. In 2020 that number rose sharply to 1,573, then tripled to 4,598 in 2021.
It seemed inevitable that the war would put the brakes on progress, but despite missiles laying waste to large parts of Ukraine’s major cities, data emerging from the first six months suggest that more patients will receive treatment for acute stroke in 2022 than in 2021.
How is this possible?
There is no standard operating procedure for fighting stroke in a war, Lev says. “There are no guidelines for it, no protocol. And in the first few weeks after the invasion no-one was really thinking of stroke. The most important thing was saving people from bombs.”
But the years-long war on stroke had left them combat-ready, and during the pandemic they had learnt to improvise.
By April the Angels team were running weekly Zoom calls for stroke physicians, a project that was supported by Drs Valeria Caso and Francesca Romana Pezzella of the European Stroke Organisation’s ESO Task Force for Ukraine. Participation soon grew from 30 to over 100 as doctors from all over the country dialed in for experience-sharing and a sense of community.
By June, the weekly call had a formal agenda that was disseminated via email. Every Thursday’s meeting included a presentation by a world-renowned stroke expert and a panel discussion lead by a local and an international moderator.
On 2 June, the day it was announced that Russia controlled 20% of Ukrainian territory, Dr Michael Mazya from Sweden’s Karolinska Institute spoke about intravenous thrombolysis in acute ischemic stroke.
On 9 June, the day Russian forces took the city of Sievierodonetsk, ESO president Professor Peter Kelly dialled in from Dublin to speak about secondary prevention after stroke.
On 23 June, the day Russian troops surrounded Ukrainian soldiers in the settlements of Zolote and Hirske, Professor Urs Fischer, head of neurology at University Hospital Basel, Switzerland, spoke about anticoagulation after stroke.
On 14 July, the day a missile strike on Vinnytsia killed 26 people, interventional neurologist Dr Marc Ribo from Barcelona, Spain, gave a lecture on thrombectomy and aspiration.
The weekly call offered doctors a chance to grow and learn from the best minds in the world. For those who had lost a family member, their hospital or their home, it made them feel less alone.
During blackouts in occupied cities doctors attended these weekly meeting using their mobile phones in darkened corridors. By now everyone in Ukraine knew the rule of two walls. One wall stops the projectile, the other protects from shell splinters. You’re safer in a corridor. Wear warm clothes in case your building is destroyed.
Simulation training resumed in June. It still wasn’t safe to travel to Poltava, so the Poltava team conducted simulations at hospitals in the western cities of Uzhgorod, Mukachevo, Khmelnytskyi and Lviv. Training for ambulance teams and nurses moved online; there was a summer stroke summit in June, and plans for a stroke academy in October. Meanwhile work continued in Armenia, Georgia, Kazakhstan, Kyrgyzstan, Moldova and Uzbekistan. “The more we have to do, the more we do,” Lev says.
In the month after the war began, 370 stroke patients in Ukraine were treated with thrombolysis. In April the number rose to 437, and to 457 in May. In June the number of patients treated for acute stroke (527) exceeded that of the previous year.
Lev and Maria are quick to point out that these statistics do not reflect the situation throughout the country. Rather, they tell a story of more hospitals starting to treat stroke in regions less impacted by the war. Implementation of the government policy for stroke continued with scarcely a pause, only in a new location for the time being.
Even the war couldn’t stop our project, Lev says. “We understood we had to stay calm. We understood that physicians needed the support of a community.
“We already had a good Angels model. When we shifted our focus to the west where stroke treatment wasn’t done previously, we adapted it to the new circumstances. It could easily be done. Even in wartime, the Angels model held.”
The influx of doctors from the east of the country meant stroke care could be expanded to previously underserved regions. As the migration continued, requests for stroke bags and simulation training were coming from hospitals that had never treated stroke before. More checklists had to be printed to keep up with demand.
“All of our physicians continued to work during the war,” Tamara says. “They’re the bravest people in the world. Even if they had to leave their city, even if their hospital was destroyed, they would instantly go to another hospital to help.”
There are stories that it’s still too soon to tell. Like the one about the doctor in hard-hit Sumy in northeastern Ukraine who treated a stroke patient in a door-to-needle time of 10 minutes, four weeks into the invasion. These are stories that will be told after the war.
Lev has stayed in Ukraine and is now living in Kyiv. On 27 February, just three days into the war, he applied to work as a voluntary physician. When he has free time from these and his military duties, he travels to newly liberated territories to provide medical care.
As a doctor before joining Angels he had worked in remote rural areas of Ukraine and provided emergency medical assistance to victims of floods and typhoons in the Philippines. This is not, one might say, Dr Prystupiuk’s first rodeo.
Tamara and Franck spent three months living with Franck’s family in their tiny apartment in France. In June, when most of the fighting had shifted to the south and east of the Ukraine, and the capital seemed relatively calm, they came back to Kyiv where baby Margaux was born on 6 September.
But on 10 October when Russian missiles once again rained down on the city, two explosions close by shattered windows in the neighbouring building, and they spent the next two days in a bombshelter.
“Running to a bombshelter with your one-month-old baby while hearing the missile siren and watching windows explode, it’s hard to describe,” Tamara says.
After 10 days underground, an “angel” saved Maria and her family from the war. An ambulance arranged by the EMS director for the region helped them escape from the shelter and their district. Past the ruined school, through battle-scarred streets and a menacing forest, the 10 km ride to the station seemed to last a lifetime.
Then they crowded onto a train bound for Lviv, Maria’s luggage consisting of the bag she had packed for her two-day trip to Kremenets two weeks earlier.
With Lev’s help they eventually reached the border with Romania where they stood in line for six hours. When a trumpet player started playing the Ukraine national anthem, they left their country singing:
“The glory and freedom of Ukraine has not yet perished ....”
Maria, her daughters and her mother are now living near Ingelheim in Germany and the children are attending school. “I already like this city,” she says, “although the tree near my home (in Kharkiv) is different from all the other trees in the whole world.”
In August Maria took Dasha and Varia to the seaside. Seeing her daughters on the beach, whole and happy, she was struck by the thought that they were among the lucky ones.
Will she go back to Ukraine? “I would like to go back to before 23 February,” she says.
Maria searches for the words to describe the compassion and generosity she has received from her colleagues; she is glad above all to be doing work that feeds her soul. At least until she sees the tree near her house again, "Angels is a country, a community, a home".