War in Ukraine: A guide to MSF's ambulance train

In Ukraine, an innovative ambulance train transports critically ill patients from hospitals in the east to treatment and relative safety in the west.

Elvina Motard, Médecins Sans Frontières / Doctors Without Borders (MSF) systems engineer, and Christopher Stokes, head of MSF in Ukraine, take us inside a life-saving project on rails.

“Back in the first week of March, Kyiv was being surrounded and convoys of civilian vehicles were being hit,” says Christopher.

“The team I was with had been evacuated to Lviv in the west of Ukraine… but then I noticed that the trains were still working. After a bit of negotiation with the railway company and some authorities, we were loading a train with our existing medical supplies. It left for Kyiv that same night."

Both Christopher and the railway company were impressed – they’d never seen this kind of aid convoy before. So, as the train arrived in the capital the next morning, Christopher asked another question: “What if we could evacuate patients by train, too?”

“We realised that building a train with an onboard intensive care unit would take time to get right, so to test the concept we started with a ‘basic’ train that could evacuate less critical patients. The wagons still required a lot of modification and we needed a team of medical staff, but we had it on the rails within weeks. It was the first time MSF had ever tried anything like this.”

Meanwhile, while this team began preparing a preliminary train that could transfer clinically stable patients, Elvina’s team was tasked with the complicated job of preparing a train that could transport patients who needed intensive care.

“One of the biggest hurdles we faced from the start was oxygen,” says Elvina. 

“If you’re transferring intubated intensive care patients, you need to have a large oxygen supply and a specific area of space around each patient. It requires a certain layout. It was clear from the start that there were a lot of complex problems that needed to be solved.

“When we design a hospital, we work hard on the flow and the positioning of everything. How are patients and medical staff going to move around the space? Where does the waste go? We look at all the ins and the outs. 

“But on a train there is one single line of movement, and everything and everybody – patients, medical staff, technical staff, food and waste – has to flow along that line.”

“The key thing we learned from going to see the smaller medical train [for clinically stable patients] in action was how difficult it was to move patients inside the train,” says Elvina. 

“As a result, we expanded the space within our carriages to give more room to manoeuvre stretchers.”

“One of the biggest technical difficulties we faced was the energy supply,” says Elvina. 

“Each carriage had its own energy production and its own water supply but, because of the amount of equipment required, our energy needs were going to far exceed what the individual carriages could provide. We ended up devoting a whole carriage to the generator and batteries.

“However, this created another problem. For the intensive care unit to be properly isolated, and so that people wouldn’t be passing through it on their way to somewhere else, we had to put it right at the other end of the train. This meant that the most energy-hungry part of the train was furthest from the energy supply. 

“The solution was electrical cable, approximately two kilometres of it, running through the train.”

“We designed each carriage to be modular,” says Elvina. 

“We put hooks everywhere: hooks for the medical equipment, hooks for all the stretchers and beds, hooks for storage. This means we can add beds or take them away and even reconfigure entire carriages, depending on the number and type of patients we’re transporting.”

“We struggled with the heating,” says Elvina. 

“It was still very cold in April when we put the train together, but the carriages were so old they relied on charcoal heating. How could we make that safe and how could we ensure it didn’t compromise our infection prevention and control measures? 

“We came up with some tricks with the flooring to make it work, but soon after that the weather turned warm and we had to work out how to create an effective cooling system.”