Oleg Musiy. Photo source: 112.ua
The largest ambulance procurement in Ukraine's history saw two health ministers gain publicity: Raisa Bogatyreva, who oversaw the purchase, and Oleh Musiy, who oversaw the acceptance of the vehicles.
The ministers' affiliation with opposing political camps did not prevent officials from introducing vehicles that pose a threat to the lives of doctors and patients.
Throughout the procurement process, Ministry of Health officials maintained that all purchased vehicles were of the highest quality, manufactured in accordance with existing standards, and that the installed equipment was from renowned European manufacturers. However, as it turned out, doctors had a number of concerns about the quality of the vehicles.
All NPO Praktika vehicles are equipped with unregistered devices for heating infusion solutions to a temperature of (37±2)°C. The list of equipment installed on new NPO Praktika emergency medical vehicles under the "Equipment Name" column states "Included in the ambulance interior equipment."
It should be noted that anything used for invasive procedures (involving penetration of the patient's body) must have not only a quality certificate but also a certificate of state registration from the Ministry of Health. The Agency for Journalistic Research (AJRI) contacted the State Service of Medicines of Ukraine (which conducts state registration of medicines and medical devices) asking for confirmation that a solution heating device labeled "Included in ambulance interior equipment" manufactured by NPO Praktika has a certificate of state registration.
Although the State Service for Medicines had previously responded independently to all inquiries from the Agency for Medical Industry (including similar ones), it was this letter that prompted it to contact the State Enterprise "Polytechmed" (a state-owned enterprise that certifies the compliance of vehicles with current legislation and standards). Here is an excerpt from the response signed by the enterprise's director, Rostislav Kartavtsev:
In accordance with the requirements of DSTU 7032:2009, the interior of ambulances (hereinafter referred to as AMEs) must be equipped with specialized medical equipment. This includes the possibility of incorporating separate equipment directly into the interior when converting the base vehicle. Type B and Type C AMEs manufactured by NPO Praktika, which are based on the Peugeot Boxer but are duly registered, utilize a device for heating solutions to a temperature of (37±2)°C. This device is part of the AME conversion, meaning it is firmly attached to a special location in the interior and is an integral part of it. The device's purpose, technical specifications, and use are fully described in the AME operating manual. A separate state registration certificate for this device is not required.
What's surprising isn't so much the answer, but why NPO Praktika's management decided to install only "home-made" solution heaters, hiding it under the guise of a refurbishment procedure. After all, almost all the equipment in the ambulance is rigidly mounted, meaning, according to the logic of the Polytechmed State Enterprise's management, it doesn't require state registration! Defibrillators, stretchers, monitors, and electrocardiographs could all have been labeled "Included in the ambulance interior equipment," and even uncertified equipment from third-world countries could have been installed in place of expensive items. Clearly, such a configuration would have caused a scandal, but the 1159 solution heaters should have gone unnoticed.
Other manufacturers didn't opt for NPO Praktika's scheme. City Transport Group LLC submitted a heating device manufactured by Dnipropetrovsk Bus Plant LLC; Avtospetsprom LLC submitted a Bicaksilar Tibbi Cihazlar Sanayi ve Ticaret AS (Turkey); and Global Avtogroup LLC submitted a TahatAxi LLC (Belarus). Only NPO Praktika, which won the most bids, decided to profit from equipment that lacked state registration with the Ministry of Health.
An infusion system that allows the use of fluid heated to blood temperature (37±2)°C is mandatory in Class B and C vehicles according to DSTU 7032:2009 of Ukraine. Sergey Dubrov, Associate Professor of the Department of Anesthesiology and Intensive Care, explains that using a poor-quality device for heating fluids can lead to catastrophic consequences. "It is important that the solution is at a temperature of (37±2)°C. If the solution is administered at the wrong temperature, it can worsen vascular spasms or cause shock in the patient. This can lead to peripheral blood flow and, as a result, reflex cardiac arrest," says Sergey Dubrov.
A heating device is used in cases of low body temperature and to combat hypothermia (hypothermia), which can lead to cardiac arrest. Heated fluid allows for more effective medical care. The solution has no therapeutic value on its own; it must be used in conjunction with other treatments. The solution must be at the correct temperature when entering the vein itself, as it may cool as it flows through the thin tube.
"If you administer a cold solution, the patient will become chilled. If someone is hypothermic and then given cold fluid, resuscitation will be ineffective. However, if there is trauma or blood loss and the patient is cooled with a solution, complications may develop later. The outcome of subsequent surgery and treatment will depend on this. Infusing a very hot solution will cause blood clotting, which can lead to blood clots and death," explains Vitaliy Krylyuk, Chairman of the Board of the All-Ukrainian Council for Resuscitation and Emergency Medical Care.
Photo source: newsprolife.com.ua
Incidentally, NPO Praktika also produces its own stationary oxygen cylinders, labeled "Part of the Ambulance Interior." However, according to current regulations, state registration is mandatory not for oxygen cylinders, but for medical oxygen. This is after the dangers of these cylinders were exposed to the entire country on January 18, 2010, when an oxygen cylinder explosion at Hospital No. 7 in Luhansk claimed the lives of 16 people. State Service for Medicines officials require manufacturers to register the vehicles themselves as medical devices (a corrupt mechanism for blocking undesirable manufacturers), but they ignore the most important products and equipment.
But this isn't a complete list of the threats facing ambulance patients, which, for some strange reason, received only positive reviews from the Ministry of Health and the State Enterprise Polytechmed. 103 ambulances manufactured by IP AIS-Stolitsa are equipped with cabinets that could be called "death cabinets." To the left of the patient's head is a cabinet where crew members can store items, equipment, consumables, and stair rails. The key feature of these cabinets is that they have no lock or fastening, meaning that in the event of an accident, if the ambulance were to fall on its side or roll over, the entire contents of the cabinet would fly into the patient's head and into the medical staff.
"In the event of sudden braking or an accident, unsecured objects can seriously injure passengers. An object that falls at high speed due to inertia can cause a traumatic brain injury, a concussion, or even a bone fracture. Essentially, unsecured objects in a car become projectiles in an accident that can not only injure but also kill passengers. And for patients, the risk is even higher, as they may be unconscious," explains emergency physician Ruslan Soltysyuk.
The much-discussed seats in NPO Praktika vehicles also remain a problem. According to DSTU, there's nothing to criticize. However, the placement of these seats defies logic. The side seats, when open, are positioned close to the stretcher. This means the doctor can only sit facing the direction of travel, not the patient. Or they can spread their legs as wide as possible, which poses risks while the vehicle is moving. Doctors and medical workers insist that even while the vehicle is moving, they need full control of the patient. In the event of an accident, this leg position could be particularly dangerous for medical personnel.
However, none of the seats offered by the winning bidders meets all the needs of a paramedic or doctor while working with a patient. For example, if a paramedic needs to manipulate a patient's legs, they must stand up from the seat, which is mounted in the floor. In some European countries, a special lever allows the seat in ambulances to be moved longitudinally along the wall from head to toe, saving time and maintaining a comfortable position.
All these facts indicate that the current DSTU is not ideal, and relying on manufacturers' conscientiousness is simply unrealistic. This is despite the fact that the Ministry of Health, by procuring ambulances through a single tender, is handing over excess profits to manufacturers, depriving itself of the opportunity to save public money.
The development of an emergency medical vehicle consists of three stages. The first is purchasing the chassis, the second is purchasing the necessary equipment, and the third is installing the equipment and converting the chassis into an ambulance. Instead of independently determining the chassis, equipment, and conversion cost, the Ministry of Health delegates its authority to conduct public procurement to entrepreneurs incapable of creating a safe vehicle.
This scheme not only leads to a loss in vehicle quality and a risk to patients' lives, but also leads to serious financial losses. Let's try to calculate the state's losses on purchasing ambulances.
It is known that the price of a B-class car at the time of the tender was approximately 650,000 UAH. After the change of power in the country, representatives of the Peugeot dealership in Kyiv, Vidi Avenue, stated that they were pressured by the Ministry of Revenue and Duties and were forced to remove the markup on their cars. The dealership sold a Peugeot Boxer to NPO Praktika for 205,400 UAH per unit. Let's assume that, using transparent schemes and conducting procurement independently, the state would not have resorted to such draconian methods, and the price per car would have been 215,000 UAH.
We know another fixed figure that determines the final price of a car. Back in September 2013, at a car presentation at the Ministry of Health, manufacturers announced their production capacities and the cost of converting a car. Vidi Avtogroup quoted approximately 160 UAH for converting a car to the B-class, Avtospetsprom LLC – approximately 180 UAH, and NPO Praktika – at least 250 UAH. If the Ministry of Health held a separate tender for the conversion, it would select the company with the best price. Let's take the average price offered by Avtospetsprom LLC – 180 UAH.
Now, the cost of equipment. This is one of the most complex and opaque stages of ambulance development. The fact is that with such huge volumes, equipment suppliers not only compete for the lucrative budget cuts but also offer discounts that can exceed 50% of the list price. We know that all manufacturers produce equipment of roughly the same class, so let's take the figure from the manufacturer that spent the least. Vidi Avtogrup would have spent approximately 275 UAH on equipment, Avtospetsprom LLC would have spent 255 UAH, and NPO Praktika would have spent around 195 UAH.
Adding up the work, we arrive at the cost of one B-class vehicle of 590 hryvnias. Thus, by the most basic calculations, the Ministry of Health overpaid (or, more accurately, wasted budget funds) by 10%.
Nevertheless, the Ministry of Health has no plans to abandon the vicious practice of inefficiently using public funds. Sources say that if a tender for the purchase of new ambulances is held next year, it will only be under the old model, whereby a single manufacturer, lining its pockets with excess profits, can supply the state with hundreds of ambulances that can endanger the lives of patients and doctors. But this has long ceased to be a concern. After all, as long as there is a shortage of vehicles, crews are happy to receive any new ones. And the pace of ambulance fleet renewal is such that ambulance stations will forever live with this shortage, hoping that next year they can replace at least a few vehicles.
Note: After all ambulances were dispatched to the regions, the number of vehicles under five years old is approximately 2700. Before the large-scale procurement, the number of ambulances stood at 3389, of which 761 required major repairs. Another 769 vehicles were scheduled for decommissioning. Therefore, Ukraine's ambulance supply is approximately 60%, with a shortage of 1861 ambulances.
Maxim SHPACHENKO, Vladislava KOZAK, Journalistic Research Agency, especially for RBC-Ukraine
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