Story by Ellie Kollme
A new ultrasound protocol developed in 2022 has saved more than 10,000 lives on the Ukrainian battlefield and is making its way to the United States, according to Dr. Oksana Popova, a civilian surgeon and ultrasonographer.
The protocol, FAST-U, is a hand-held ultrasound sonographic procedure designed for combat settings. It is an adaptation of the Focused Assessment with Sonography in Trauma (FAST) protocol, which uses an ultrasound to detect internal bleeding in trauma patients.
Ultrasounds use sound waves to create images of the inside of the body and are not limited by location, time, electricity, water or internet, according to Popova.
FAST protocol is a specific type of point-of-care ultrasound (POCUS), used by health care professionals to detect patients’ conditions and make medical decisions. The FAST-U protocol builds upon the traditional FAST exam by including colon and retroperitoneal assessments.
It evaluates colon injuries by looking at the changes in colon diameter on a POCUS scan. It can detect whether the colon is spasming, which is usually a sign of rapid blood loss. This can help discover internal bleeding.
The “U” in FAST-U stands for Ukraine. The probe is connected to a tablet and enables medics to rapidly detect abdominal injuries.
In the past, ultrasounds were not commonly used to detect large bowel injuries because gas in the colon interferes with the sound waves, making it difficult to get clear images. It took Popova three months of visiting different surgery departments in Ukraine to test the protocol and assess its effectiveness. She said she thought it would be “impossible.”
“If somebody told me in 2022 that I would provide this course for combat medics, I would have told this person, ‘You are crazy,’” Popova said.
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Since Russia invaded Ukraine in 2022, uncontrolled bleeding from traumatic injuries has been a major cause of death among Ukrainian soldiers. Popova was tasked with finding a solution to this problem with the use of an abdominal ultrasound.
On May 19, 2022, Popova had gathered enough case data to validate her findings with the FAST-U protocol. She had evaluated 22 clinical signs and symptoms of abdominal bleeding and discovered that a colon injury could be identified by observing a colon spasm.
“It was a very historical day for me,” Popova said.
After demonstrating FAST-U’s effectiveness in May, she began integrating the FAST-U protocol into her training sessions.
Nathan Stokes, the program manager for Carolina MEdIC at UNC Health, said FAST-U enables combat medics to assess injuries on the front lines, enabling them to make more informed decisions without a CT scan or an MRI, while also having the ability to monitor injuries with ongoing assessments.
Carolina MEdIC is a military-civilian partnership program that was launched as the UNC Trauma Military Education Immersion Center in 2019, according to the UNC School of Medicine.
The implementation of FAST-U has reduced mortality from abdominal injuries during the war in Ukraine by half, according to a Training Center ELLING 2019-2025 report. ELLING, founded by Popova in 2019 and headquartered in Dnipro, Ukraine, aims to save lives and improve the quality of medical care in Ukraine, with a particular focus on emergency ultrasound training for trauma care.
Popova is a medical officer in the Armed Forces of Ukraine, assistant to the Head of Clinical Work at the Military Medical Clinical Center of the Eastern Region (Ukraine) and a board member of the European Association of Surgeons. She is also a WHO-Certified Health Cluster Coordinator, a fellow at the American College of Surgeons, the director of ELLING and a trainer in ultrasound and health care management.
She was born in Nikopol, Ukraine, and currently lives in Dnipro, Ukraine, where ELLING is located.
According to Popova, 566 probes and tablets have been provided by the nonprofit Razom for Ukraine, a Ukrainian-American organization she has been working with since 2022 that promotes a secure, prosperous and democratic Ukraine.
The POCUS probes are made by Butterfly Network, a company that produces hand-held ultrasounds. According to the Butterfly website, its goal is to democratize health care by making medical imaging accessible around the world. Razom purchases these Butterfly probes from ELLING using funds donated by private supporters.
Alex Domaradsky, Razom co-pilot project coordinator, said Razom has no government funding and that it is the private American donations that enable them to save lives.
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Since the development of FAST-U, Popova has been traveling through Ukraine and North America to share her work through presentations and training sessions.
She went to Montreal, Canada, in 2023, where she presented at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2023: Innovation for the SAGES, the 10th Annual Military Surgical Symposium. She received the Colonel David G. Burris Award For Excellence in Trauma And Surgical Critical Care Research, and the Recognition of Excellence by SAGES.
Aside from Canada, she visited Florida and North Carolina in August. Popova said she enjoys traveling to America to share her expertise.
“It’s a place where people are ready to hear something new that you bring here, a place that I feel freedom,” Popova said.
ELLING has had 254 events, 222 trainings with 3,336 participants, 33 webinars with 407 participants and a total number of 3,742 trainees. ELLING had 16 permanent specialists in various fields and 12 invited experts as part of their instructor team. Popova has conducted most of her trainings in 11 regions across Ukraine.
Popova herself has hosted 110 events and has trained 2323 participants–1444 military and 879 civilian medical staff–outside of ELLING.
Domaradsky said Popova trains anyone who is interested, ranging from bankers to medics. She said it takes Popova about a week to train students, but it depends on their medical background. She mentioned that a problem with training in Ukraine is there is a lot of information to learn in a short period of time, as trainees have to learn anatomy, physiology and ultrasonography.
“Those scans are difficult to read, and are not very intuitive,” Domaradsky said. “But once you figure it out, I think even a common person without a very extensive medical background can understand it.”
Domaradsky said that Popova does a good job keeping things interactive, which helps people stay encouraged and excited.
“It’s possible to teach any person,” Popova said. “It’s an important part of my work, training, because the protocol will die without a person who will implement it.”
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Popova came to UNC-Chapel Hill from Aug. 13-15. Stokes arranged for her to visit with Dr. Ben Smith, the medical director for Carolina Air Care, the air medical helicopter and critical care emergency transport program for UNC-CH.
Smith met with Popova and she described the specialized ultrasound training she provides in Ukraine and explained the origins of FAST-U. She also introduced a glossary she has developed based on three years of colon injury data, which she uses to guide medics during trauma assessments.
Smith has experience with ultrasound through Carolina Air Care, which uses extended Focused Assessment with Sonography in Trauma (e-FAST) protocol when flying patients to trauma centers. E-FAST is another adaptation to the FAST protocol that looks at the chest, pelvis and the right upper and left upper quadrants in the abdomen.
Smith said Popova’s colon injury data would be valuable in combat environments, and that FAST-U would be limited to military settings because most patients in the United States can be at a trauma center quickly enough to get a CT scan.
He said he does not think FAST-U will directly change how UNC Health manages trauma patients, but that it could help validate Popova’s research through a long-term data collection process.
Stokes said the FAST-U protocol is beneficial for hospitals in rural North Carolina that do not have access to a CT scan, while also being a cheaper alternative. He said techniques like FAST-U can help reduce delays when getting people to definitive care.
“I think it has a lot of value here in the United States and rural medicine and rural health care, where it can be used as an adjunct for more in-depth scanning techniques and imagery techniques that may not be available at rural hospitals,” Stokes said. “As relevant and important as it is on the battlefield in Ukraine, it’s got huge potential here in the States for the exact same reasons,” Stokes said.
Popova agreed with Stokes’ sentiment on the use of the probe in the United States.
“I see a huge possibility to implement this data consistently to low-cost facilities,” Popova said. “And why not? It will be useful. I would like to share it with anyone who needs this information.”
Stokes said he believes UNC-CH could drive change with the resources it has. He said it would take grassroots implementation to see if military learners would want to add FAST-U to their practice.
“We forget this is a special place, with some of the best minds in the world, with some of the best resources in the world, and with an incredible reputation,” Stokes said. “If we can get those things to work together, we can create real movement and change.”
Domaradsky said she hopes Razom will have a partnership with UNC-CH in the future, and is hoping to come back in the spring to host a multi-day training session.
Additionally, the Special Operations Medical Association (SOMA), an organization that enables military and civilian medical providers to exchange ideas, is hosting a conference in April in Raleigh, North Carolina that Razom is attending.
Domaradsky said that despite the ongoing tragedy in Ukraine, she is hopeful. She said Ukraine is making huge medical strides in combat medicine, and advancements like FAST-U will be the future of military medicine.
“There’s a lot of lessons learned because there’s such a high need for innovation and improvement, especially in a war context,” Domaradsky said. “There is a lot Americans can learn from Ukraine, not just for improving our military readiness and preparedness, but also things that can be used to improve American health care systems.”
