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.
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“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.”
In numbers: MSF’s ambulance train
In 2022, more than 2,500 patients were evacuated along with their family members. On 11 April, 78 babies and toddlers were also evacuated from an orphanage in Zaporizhzhia.
In the first six weeks alone of 2023, a further 215 patients have so far been transported.
- 39 patients per journey (plus around 20 lightly-injured patients)
- 196 metres length of the train (excluding locomotive)
- 50 kVA capacity of the generator
- 7 oxygen generators for high flow oxygen in the ICU
- 400 litres of water capacity per carriage
- 39 batteries
- £502,000 approximate cost of supplying the train with equipment and medicines
Working with a team from Ukrainian Railways at an undisclosed location in Ukraine, MSF’s team of four began to work on turning eight railway carriages from the 1980s into a cross between an ambulance and a state-of-the-art intensive care unit.
“It was a massive challenge, but also intense and inspiring,” says Elvina.
“The four of us from MSF (along with our colleagues in Brussels) brought our experience of medical facilities and of working in emergencies. The 50 or so Ukrainian Railways workers brought their knowledge of train engineering.
“Somehow we had to work together to find solutions and create something that would work for patients and staff.
“There were disagreements, language barriers and constant interruptions from air raid sirens and evacuations. We worked out that each one of us walked around 13 km every day on site, up and down the train and all around.
“It was exhausting, but we worked together, learnt from each other and never forgot why we were doing it. And after 23 days, we had the medical train we’d envisioned.”
Help us prepare for the next emergency
“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.”
MSF and the war in Ukraine
Fighting in Ukraine has killed or injured thousands of people, while more than 9.1 million refugees have fled to neighbouring countries.
Médecins Sans Frontières / Doctors Without Borders (MSF) teams are working to deliver emergency medical aid to people still in Ukraine, as well as those now seeking safety in neighbouring countries.