Discussion

In this study, we report the effectiveness and acceptability of implementing CBRNE training courses in Ukraine to improve knowledge and enhance confidence with practical hands-on skills. There are limited studies describing the availability and evaluating the effectiveness of CBRNE training in Ukraine. Regarding other Ukrainian CBRNE training courses, in November 2019, just before the COVID-19 pandemic, health experts from Ukraine, the United States, United Kingdom, Czech Republic, and Norway convened to conduct “Emerging Technologies and Countermeasures to CBRN Agents: Advanced Training Response to Conflict and Security Challenges in East Ukraine”. This event was sponsored by the North Atlantic Treaty Organization (NATO) Science for Peace and Security Program and held at Mechnikov Hospital, in Dnipro. ^{Reference Patel, Grace and Chellew3} In the wake of the armed 2014 Russian–Ukrainian conflict that unfolded in East Ukraine, this teaching hospital scaled-up and transformed itself into a trauma response center treating thousands of soldiers and civilian casualties and served as the setting for this advanced training course.

During more recent stages of the war, to develop practical hands-on skill stations and drills, we reviewed potential chemical, biological, and radiologic weapons historically produced and used by the Russian Federation (or its allies) ^{Reference DeLuca, Chai and Goralnick6} to identify plausible risks to Ukraine military personnel and civilians. ^{Reference Tin and Ciottone13} We also prioritized preparedness, rapid assessment, and treatment guidelines to recognize and manage these acute exposures in wartime settings. Evaluating a potential CBRNE exposure should also emphasize (1) immediate life-saving interventions and resuscitation (2), evacuation from the exposure (3), diagnosis of syndromic symptoms or toxidromes, and (4) supportive care and antidote therapy, as described in Figure 2). ^{Reference Chai, Berlyand and Goralnick5}

Figure 2.

Syndromic identification and treatment of a potentially CBRNE agent exposure.

For agents with reversal agents, administration of antidote therapy soon after the exposure (such as in the prehospital setting or battlefield) may increase survival and decrease the use of scarce critical equipment (intravenous fluids, ventilators), medical staff (emergency or critical care specialists), or space (hospital beds) in an already fragmented health-care system. ^{Reference Davidson, Magalini and Brattekås4,Reference Chai, Berlyand and Goralnick5} First responders at the scene of a potential CBRNE attack should don PPE if available to avoid secondary contamination. Exposures may result in characteristic physical examination findings which may guide the administration of antidotes and other life-saving treatments. ^{Reference Ciottone14} Our practical hand-on drills emphasized vital sign stabilization and physical examination findings performed in the field, ^{Reference Burkle15} with initiation of treatment as early as possible, in the prehospital setting. Importantly, for individuals exposed to weaponized organophosphates and radioactive particles, decontamination should occur outside the hospital to prevent secondary exposures to health-care workers and other victims, although this may be a challenge in the setting of war with artillery exchange and cold winter conditions. Rapid triage should be performed by responders also equipped with appropriate level PPE to perform life-saving measures consistent with Sort, Assess, Life-saving interventions, Treat/Transport (SALT) triage methods or similar disaster triage algorithms. ¹⁶ Once emergency care and decontamination are complete, secondary triage can be performed to match clinical needs with available resources to balance demands of mass casualties. The practical skill stations and drills conducted in our CBRNE courses prioritized these rapid response, decontamination, and treatment principles.

The CBRNE response training further focused on 3 recommended levels: organizational (policies, procedures, and preparedness); technological (decontamination, security, and treatment); and individual provider (PPE, knowledge, and practical skills). ^{Reference Razak, Hignett and Barnes17} The first dimension of response and recovery from a CBRNE event encompasses human resources, by expanding the number of properly trained front-line emergency responders in Ukraine. The second dimension is interoperability. Coordination of CBRNE preparedness and response efforts is necessary to maximize readiness, response, and adequate equipment in an austere war-torn environment. ^{Reference Smith and Weir18} Other studies have documented similar trauma training courses in austere prehospital settings. ^{Reference Jayaraman, Mabweijano and Lipnick19,Reference Eisner, Delaney and Thullah20} A third dimension is developing in-country expertise with strategic thinking and innovations in low resource settings. Capacity building efforts should focus on emergency and mass casualty response but also CBRNE teaching opportunities for new experts in Ukraine to address current and future threats. ^{Reference Patel, Grace and Chellew3,Reference Coleman, Bader and Koerner12} This key concept was the basis for our innovative Train-the-Trainer program. Other programs (Turkey 2006, Finland 2009, Uganda 2020, Slovakia and Sweden 2022) ^{Reference Kenar and Karayilanoglu21–25} have implemented similar CBRN training models but not in the setting of an active war.

Regarding our data, knowledge assessment test scores and self-assessed confidence scores improved significantly after completion of the CBRNE course for both health-care providers and non—health-care providers. Highest confidence rate increases at the completion of the course were: necessary skills to provide care to patients after a CBRNE emergency, ability to recognize signs and symptoms of a potential CBRNE exposure, developing an organized approach that prepares for care of CBRNE-exposed patients, selecting appropriate PPE for the type of event or potential exposure, and having skills to decontaminate patients safely. Lowest confidence rate increases included: emergency management of blast injuries, emergency management of CBRNE-injured or exposed children, understanding of emergency drugs, and the ability to document forensic findings of a potential CBRNE event. The lower self-confidence in these emergency management or “clinical” skill areas may be attributed to the fact 41% of participants were non--health-care providers.

To our knowledge, this was the first CBRNE field course to be conducted in Ukraine using real-time translation since the onset of the February 2022 invasion. This implementation demonstrated the feasibility of a structured CBRNE course to train providers working in combat or civilian settings. Many of the participants reported that the knowledge and skills acquired during the CBRNE courses prepared them well in case of a real event. The ability to simultaneously train providers from diverse backgrounds was also exhibited. Participants included health-care providers (prehospital providers, nurses, physicians) and non—health-care providers (engineers, police, security, teachers, civil servants) who may need to function as first responders to CBRNE events that require timely interventions with limited resources. The benefit of the course may vary by specialty training and years of experience and further research should explore this concept as our study was underpowered to perform subgroup analyses. Feedback from participants reflected a need for more dedicated equipment and additional skills practice, yet this must be balanced with the cost of equipment and removing practicing health-care providers away from patient care and non—health-care providers from work duties for longer multi-day courses.

This CBRNE course was the first step in implementing a structured training curriculum throughout the country in several strategic locations. Nearly 10% of participants in our courses voluntarily completed an additional advanced Train-the-Trainer program with the objective of establishing dedicated regional training centers in Ukraine in each major city (eg, Kyiv, Dnipro, Odesa, Kharkiv, and Lviv). This will also allow for in-country trainers to lead additional courses in other less populated and difficult to access regions with the goal of strengthening CBRNE preparedness throughout Ukraine. Future studies assessing knowledge retention, impact, and sustainability of this Train-the-Trainer model will be implemented.