The path to becoming a neurosurgeon in the developing country of Ethiopia begins in primary education and progresses through a gauntlet of achievement challenges through early adulthood. Ayder Comprehensive Specialized Hospital, the teaching hospital for Mekelle University, is currently training 16 neurosurgeons for Ethiopia and surrounding countries.
As children they often grew up in a multi-generational house without electricity or running water. Time to travel to and from school everyday is measured not in minutes but in hours. Before and after school they have to help maintain the house and family income such as caring for livestock, farming, or doing labor.
When they go to primary school they initially speak the first language they learned from their family (Tigrinya, Oromifya, Sedamo, Afar, Grogi, etc.) but must then learn Amharic and English progressively in elementary and secondary school. If they are lucky enough to have a television set watching it can give an advantage to learning English. To get a chance at college they must show significant reading and writing skills in the three languages by the 10th grade.
At the end of their 12th year of secondary school they have to take a national competitive exam. Science and most studies in university are taught in English so competence is mandatory. The top scorers get a chance to attend medical school for a little over 2000 places currently.
For six years in medical school they are apart from their families for the first time. Living in crowded concrete dormitories with frequent water and electricity shortages, bedbugs, and a monotonous diet of little else but shir0 with enjera are common experiences. The last year of medical school they function as an intern which is really on the job experience that is very demanding in terms of hours and responsibility.
To get into a residency program to become a specialist requires getting a sponsor, usually a university or regional health bureau, and then competing for the few hundred slots by interview, grade record, and more testing. For example in Neurosurgery last year there were 21 slots only for the whole country. If they get into specialty training, the pay is poor, less than a hundred dollars a month and they have to find some kind of housing. Usually they end up renting a room in a house for sixty dollars a month. They will work 12+ hours a day and have to spend the night in the hospital about every third or fourth day working all night to care for patients. The training program lasts five years with one month of vacation per year.
The modern concept of physician training is that it is a triad of knowledge (basic science and clinical medicine), skill (examining patients, interpreting diagnostic tests, surgical skills, etc.), and professionalism. In the first year of training they have to learn how to care for trauma patients and critically ill patients. During this year they have to master the basic skills of general surgery before they can formally begin neurosurgery.
From the second year through the fifth year they have to learn the equivalent of a PhD in neuroscience, be able to save a critically ill patient, finely interpret magnetic resonance imaging and CT scans, master fine technical skills with eye hand coordination greater than the finest musicians, and demonstrate capable leadership skills to lead medical teams to save lives. They need to read about and comprehend about 500 to 800 pages of books and journals every three to four weeks.
Around the world, the British model of training surgeons has been adapted which is what we call competency based. Neurosurgical residents progress from watching how patients are cared for and undergoing surgery at first and then progressing to less and less supervision. Every day they are constantly challenged by not only the diseases they are treating but by a strong Socratic method of teaching requiring them to always explain and justify their every decision and action. Gradually they reach a point where they function with distant supervision which is the real measure of their capability. By the end of their training which has averaged evaluating a hundred or more patients in a week and participating in surgery on about 5 to 7 per week such that they have seen thousands of patients and participated in thousands of surgeries they will be competent neurosurgeons.
Very few times in the history of medicine has one man so dominated the development of a specialty that his birthday is celebrated as the day to recognize the field but that is case in Neurosurgery. The legacy of Harvey Cushing connects Ethiopian neurosurgery to his life’s work. When I entered Harvard Medical School in the Fall of 1977 I knew was interested in the field of neuroscience but I did not at first understand how I had entered into the hallowed historical grounds where Harvey Cushing made so many advances.
Harvey was destined to be a fourth generation physician who began his studies at Harvard Medical School after undergrad at Yale just before the beginning of the 20th century. After graduation in 1895 he and Ernest Codman pioneered physiologically monitoring in anesthesia which dramatically reduced the previous death rates. Subsequently he trained in general surgery at Johns Hopkins under William Halsted, the great pioneer of modern general surgery. Residency training at Hopkins was scientifically driven by William Osler who also mentored Cushing leading him to write a biography of Osler in 1926 which won a Pulitzter prize.
From 1902 to 1937 first at Harvard, then Hopkins, and finally at Yale, Cushing performed over 2000 operations of the brain pioneering surgical techniques for the treatment of brain tumors. He revealed how the physiology of the brain functions in terms of blood pressure and brain perfusion and how the pituitary gland works. Brain surgery went from being a last chance high risk procedure to having the ability to safely save lives through out the world because of his influence and teaching.
As a medical student at Harvard I saw patients on the grounds where Cushing lectured and went to operating room where Dr. Cushing performed brain surgery. I was fascinated and inspired by the life of Dr. Cushing and this experience in my early years led to my doing a special training in neuroscience as a medical student and then to train in neurosurgery after graduation.Later as resident in Neurosurgery at the University of Miami, Dr. Larry Page, who was trained at Harvard and the Boston Children’s Hospital by neurosurgeons who trained under Cushing , was our main brain tumor training surgeon.
Six years ago I started the Neurosurgery program at Ayder Comprehensive Specialized Hospital-Mekelle University in Ethiopia where today we perform over 1000 operations a year. We currently are training 16 neurosurgeons for different regions in Ethiopia as well as Somaliland and Somalia. Following Cushing’s model of a neurosurgeon who cares about the world and his patients and uses the scientific model of research to improve life, we have created a multidisciplinary research team which has made significant discoveries in the epidemic of neural tube defects in Ethiopia. Our research led to the government studying a novel prevention program of fortifying salt with folic acid.
Happy Birthday to Harvey Cushing you changed the world and helped inspire a kid from a small town in Texas to follow your example.
The probable impending crisis of COVID 19 in the medical resource poor country of Ethiopia will likely bring controversies in medical ethics decision making. When we see New York city hospitals pilling hundreds of bodies in refrigerated trucks and having severe shortages of nurses, doctors, and ventilators in the setting of the one of the world’s richest countries what does that predict for Ethiopia. If and when the crisis hits fully we know there will be shortages. Ethiopia spends about $28 per capita yearly on healthcare while the United States spends more than $10,000 per capita yearly.
Yet although the Ministry of Health mandates that each health care facility maintain and review medical ethics standards very few do. Additionally the few documents, such as the Ethiopian Medical Association guidebook on Medical Ethics, and proclamations of the Federal government deal mostly with very general cases of proper behavior.
Real issues such as how patients will be triaged (who gets the ventilator and who does not), should a patient who is “hopeless” be removed with family consent to help someone with a better chance, brain death, etc. remain unclear.
Ethiopia has strong religious convictions in the Orthodox, Muslim, and Protestant communities. How medical ethics questions and distribution of resources are decided will have to take in account the religious and cultural traditions that are unique to Ethiopia. It is better to start these discussions now with community leaders, religious leaders, and academics then rush to make them in the heat of an epidemic.
Donations to benefit the Tigray Regional Health Bureau via the Global Society of Tigray Scholar may be given as below.
Ethiopia is facing a potential unprecedented crisis from coronavirus and how she responds is complicated by factors in her culture, traditions, geography, economics, and history.
In 1963, I was an elementary school child living in the Rio Grande Valley of South Texas when I first learned about hurricanes. My father, a neurologist-psychiatrist, told us that a bad storm was coming. We had to take precautions and ride it out. This was perhaps the first time in my life I had to deal with uncertainty. Although my father looked confident I could sense that we could not know exactly what the future could bring. Hurricane Beulah hit with high winds and much rain destroying much of our town. I thought the howling winds would never end.
Now more than 50 years later I am in Ethiopia facing another type of storm. We have seen the storm form in China, attack Europe, and now with a few cases in Ethiopia it is knocking at our door. Ethiopia where I have lived since 2012 has had her share of calamity. She is an ancient civilization extending perhaps more than 10,000 years before the birth of Christ. Over the past century she has seen multiple attempts at foreign invasion, famine, and civil war. Yet her traditions and strong sense of spirituality tied to organized religion have always seen her through adversity.
As an academic physician and member of the medical faculty of Mekelle University I am very concerned and once again feeling that same sense of uncertainty I did so long ago. How will she face this new dilemma?
The Risk of Epidemic in Ethiopia
Moritz Kraemer, epidemiologist from Oxford University, has identified Ethiopia as one of the countries in Africa most at risk based upon an exhaustive analysis of asset the country possesses or not. Now that Ethiopia has several cases documented in Addis Ababa, what are the risk for spread? Adam Kucharski and his group from the London School of Tropical Health and Hygiene predict from a pre-printed study that when a country like Ethiopia has at least 3 confirmed cases there is 50% chance for the infection to become endemic and spread.
The Effect of Culture,Economics, and Geography
Africa accounts for 16% of the world population but only 1% of health care expenditures. With a 100 million population Ethiopia is the most rural country on the globe with 88% living in the countryside. Many families have incomes less than the equivalent of $20 per month. It may take hours to a day or so to seek medical treatment in a poorly equipped countryside clinic. There is little public health education with 75% of the women and 45% of the men being illiterate. There are few hospital beds (0.3/1000) population, few doctors, and limited diagnostic facilities.
Most Ethiopians do not travel outside the country but Addis Ababa, the capital, is one of the busiest airports and hub of Ethiopian Airlines which has daily flights from around the world including China and Europe. There is little doubt that this was the vector which introduced coronavirus to the country.
Ethiopians are a “touchy feely” culture like the Italians who are so troubled now. While there is little in the way of a government social safety net the people typically depend upon long standing bonds with extended family for emotional and financial support through hardship. Community interdependence is the rule. It is not unusual for people hospitalized to have many visitors and always also to have attendants (family or friend) stay the night helping to care for a patient. Trying to impose social isolation or even just social distancing will be difficult if not impossible.
The economic principle of scarcity, meaning that great value may be placed on resources which are scarce, is strong in Ethiopia. When going to the bank, airport, market, and clinic they frequently are a bit pushy because of a fear that what they are there for while run out before they get their chance. This is no doubt a left over from the Imperial and Derg times leading to distrust of authoritative promise.
When one sees the vastness of Ethiopia, about the size of Texas, and difficulty with transportation, an initial impression is that perhaps the virus will stay only in Addis Ababa. Unfortunately, that lesson was answered years ago when the HIV epidemic started with just a few truck drivers delivering goods throughout Ethiopia.
Typically when Ethiopians who are Orthodox are sick, they will often seek spiritual healing through church services, blessings, and consumption of Holy Water. In fact, every month I have patients with curable brain tumors who presented late only after pursuing this spiritual method.
Many regions of the country have no reserve to deal with pandemics. For example the Tigray Regional Health Bureau only has a budget of 500,000 birr ($15,000 USD) to deal with a potential coronavirus epidemic. The cost of a single coronavirus is test is currently $ 500 USD. The government must try to seek payment from the patient as it cannot sustain doing testing without it.
There are not more than 200 functioning ICU beds with ventilators in Ethiopia. The experience in China, Japan, South Korea, and Europe have shown that if 50% of the population becomes ill, out of that about 20% will require hospitalization, and maybe 10% will need ventilator support. Unfortunately there is no way they will be able to treat 5,000 patients on ventilators.
What Will Happen to Hospitals?
Coming out of the Imperial and Derg times when social institutions like hospitals were rare and for the upper castes they are now seen as pillars of society with an implied unobstructed access. The CDC and WHO call for restricted entry to hospitals as well as the segregation of coronavirus patients to alternate facilities could provoke misplaced fears in the population. There will have to be a clear and repeated message explaining the scientific reasoning and how such measure are really best for the population.
Just like when I was a small boy, I cannot know exactly what will happen. I will stay in Ethiopia, the country and her people I have grown to love, and pray she finds her way through this test.
At Mekelle University Department of Neurosurgery-Ayder Comprehensive Specialized Hospital we have been developing an expertise in the treatment of stroke due to rupture of a cerebral blood vessel culminating in a successful clipping of a ruptured aneurysm.
Subarachnoid hemorrhage in Africa and Ethiopia
Stroke in Africa and more specifically in Ethiopia remains an almost taboo subject. It is shrouded in superstitious beliefs of curses and hidden poisons among most of the population who receive little public health education in what schooling they attend. A significant form of stroke is that due to rupture of a cerebral artery which creates the phenomena of subarachnoid hemorrhage. It is estimated that worldwide 9 in 100,000 years of human life or 1 in 50 people will suffer a subarachnoid hemorrhage.
Although rupture of a brain artery causing subarachnoid hemorrhage may lead to sudden death there are many patients who if given advanced treatment can be saved and return to functional lives. To receive this treatment requires special trained medical centers with experts in emergency medicine, neurology, radiology, anesthesiology, and neurosurgery. Up to now these centers have been lacking in most of Africa.
How subarachnoid hemorrhage causes damage
When a brain artery ruptures it may cause severe pressure on the brain which can kill or permanently disable. This type of large clot is unusual in most patients. Instead what happens is that the blood causes surrounding blood vessels to defensively constrict limiting the blood supply to the brain. This pathological process is vasospasm. Additionally the blood leakage can lead to chemical abnormalities of sodium or the mal-absorption of a fluid called cerebrospinal fluid which normal is produced and absorbed in a balanced way. Once a blood vessel ruptures once it will likely rupture again as each day goes by, a ticking time bomb.
Treatment of subarachnoid hemorrhage and ruptured cerebral aneurysms
Successful treatment of ruptured cerebral artery aneurysms requires rapidly making the diagnosis and beginning aggressive resuscitation of vasospasm and electrolyte abnormalities. The blood pressure must be closely controlled and the patients respiratory system supported. Upon stabilization the patient should undergo timely surgery or intravascular treatment to reduce the incidence of a second deadly rebleed. Whether microsurgery or intravascular treatment is better remains controversial.
A representative case at Ayder Comprehensive Specialized Hospital
The following case is an example. A 55 year old Ethiopian grandmother suddenly complains of the worst headache of her life and goes into a coma. She is brought to Ayder Comprehensive Specialized Hospital in Mekelle, Ethiopia on the Mekelle University medical campus. Emergency physicians and internal medicine specialists stabilize her condition and perform a CT Scan which shows subarachnoid hemorrhage and suspician of a ruptured anterior communicating artery aneurysm.
The patient is comatose with electrolyte abnormalities and out of control high blood pressure. She is admitted to the medical intensive care unit where she receives supplemental oxygen, high doses of fluids to correct hyponatremia and try to overcome the vasospasm, as well as a special medication, nimodipine, which can help to counteract vasospasm.
After 2 weeks she regains consciousness and a repeat CT angiogram ( a special CT scan which shows the arteries of the brain in detail ) is done which now clearly shows a 5mm aneurysm. Now that she is stable surgery must be done soon before a fatal rebleed can occur.
She is taken to the operating room with a specially trained anesthesia team which finely controls her blood pressure during surgery. An opening is made in the front and side of the skull while under general anesthesia and carefully working under the brain the ruptured blood vessel is exposed and clipped to prevent rebleeding.
Ethiopia is facing a growing crisis in infant meningitis compounded by a false reliance on the power of antibiotics to treat the problem without definitive diagnosis and follow up.
A growing problem
As you may know north eastern Africa including Ethiopia is part of the so-called “meningitis belt” with the highest rates of bacterial meningitis in the world. Just a couple a months ago I was attending a meeting with Ministry of Health with the new five pediatric neurosurgery centers of excellence in Ethiopia where a new growing epidemic of chronic meningitis seen throughout the country was discussed. Over the past year we are seeing more and more cases of infants on an almost daily basis presenting with progressive hydrocephalus who have diagnostic cerebrospinal fluid consistent with chronic meningitis. Our average census is 5 to 8 in hospital all the time whereas a few years ago it was only one or two. Many of these children have hospitalizations of 12 weeks or more. Many have died and many are left with significant cerebral disability which could have been prevented by earlier intervention and appropriate treatment lengths.
While this epidemic seems to be worsening, Dr. Abreha (Head of Pediatrics and Pediatric Neurologist at Mekelle University) and myself are concerned that deficiencies in facilities and procedures within the medical system may be contributing to it. Unfortunately throughout Ethiopia almost no lumbar punctures are now done to diagnose meningitis. A sample inquiry of pediatric residents and interns found that 75% of them had never done a lumbar puncture. Additionally many clinics and hospitals do not even have lumbar puncture trays. A false sense of security exists that powerful antibiotics given a short period time can will solve the problem
Secondly, the lack of ability to process or even receive an CSF specimen for analysis beyond 5 PM forces the treating physicians to start treatment without first obtaining a culture which is against world wide standard of culture first then start treatment. This seems very contrarian to the frequent theme of the pharmacy and laboratory professionals in Ethiopia that there is abuse of antibiotics.
A key analysis is determining the glucose, protein, and cell count in cerebrospinal fluid. Dr. Abreha recently gave a sample of tap water to the laboratory to be tested on the automated machine and it diagnosed multiple WBC consistent with meningitis. The equipment supplied to Ethiopian hospital is not capable of accurate diagnosis. Technicians can do manual counts but these are time consuming and labor intensive. This inaccuracy has greatly impaired our ability to determine if patients are infection free which they must be before they can undergo definitive treatment for hydrocephalus which is a ventriculoperitoneal shunt.
Thirdly, around the world there is much controversy about for how long antibiotic treatment should be given ranging from 10 days to 21 days. The problem is that partially treated meningitis patients who have not been cleared from the infection often do not have fever, meningeal signs, or other clinical findings except hydrocephalus. Many infants are briefly seen for nonspecific fever and receive short courses of antibiotics in Ethiopia without specific diagnosis being made and without adequate follow up. Many of these children we believe are harboring these low grade chronic infections leading to their late appearance at Ayder Comprehensive Specialized Hospital. This creates a great dilemma as these children often require treatment of intravenous powerful expensive antibiotics from 21 days to in excess of six weeks or more until the infection is cleared by the demonstration of two negative cultures off antibiotics and normal cell counts. In addition in order for the shunt to work the protein has to be less than 150 mg/dl. Failure to diagnose an active residual infection before a shunt placement will only aggravate the infection leading to shunt removal and complications.
The treasure and future of Ethiopia is in her children. Meningitis appropriately treated early and followed can have a very low morbidity and disability outcome. The current situation if not acted upon will result in increasing medical costs, increasing disability, and increasing infant death which could be prevented with simple directed community and institutional action.
Recommended Course of Action 1. Immediate upgrade of laboratory ability in hospitals to receive CSF specimens 24 hours a day for culture, gram stain, sensitivity. 2. Training of interns and residents in performing lumbar puncture and making sets available 3. Institute an Ethiopian wide policy of obtaining CSF before starting antibiotics. Children with seizures, lethargy, focal deficit, or signs of increased intracranial pressure would be emergently sent to a referral hospital for CT Scan or if possible if they have an open fontanelle undergo an head ultrasound locally to rule out mass before lumbar puncture. 4. Make sure all children treated for meningitis undergo follow-up and that a repeat lumbar puncture is done after treatment. This may seem over kill but given the crisis happening it is the only way to prevent these chronic cases. 5. Funding of community service, public education, and research projects on this vital issue in cooperation with the regional health bureaus. 6. Training of health officers, nurses, and general practitioners in proper diagnosis, evaluation, treatment, and referral of children with meningitis and hydrocephalus.
The Department of Neurosurgery at Ayder Comprehensive Specialized Hospital of Mekelle University treats over 1000 significant head injuries every year including performing an average of 2.5 operations per day. All patients should undergo standard multiple trauma resuscitation and assessment by Advanced Trauma Life Support Guideline.
Since 2015 the Department of Neurosurgery at Mekelle University has instituted a standard head injury protocol (now revised in 2019) for the assessment and treatment of children and adults at Ayder Comprehensive Specialized Hospital based in part upon the local settings of Northern Ethiopia and the international guidelines including that of the Brain Trauma Foundation
Intracranial pressure monitoring is not economically feasible in Ethiopia but we are developing research protocols to look at optic nerve sheath diameter by serial ultrasound in the near future.
Adults Initial Assessment The management of patients with a head injury should be guided by clinical assessments and protocols based on the Glasgow Coma Scale and Glasgow Coma Scale Score.
Indications for referral to hospital Adult patients with any of the following signs and symptoms should be referred to an appropriate hospital for further assessment of potential brain injury:
1. GCS<15 at initial assessment (if this is thought to be alcohol related observe for two hours and refer if GCS score remains<15 after this time)
post-traumatic seizure (generalized or focal) focal neurological signs
2. signs of a skull fracture (including cerebrospinal fluid from nose or ears,
hemotympanum, boggy hematoma, post auricular or periorbital bruising)
3. loss of consciousness
4. severe and persistent headache
5. post-traumatic amnesia >5 minutesrepeated vomiting (two or more occasions)
6. retrograde amnesia >30 minutes
7. high risk mechanism of injury (road traffic accident, significant fall)
coagulopathy, whether drug-induced or otherwise.
Indications for head CT scan Immediate CT scanning should be done in an adult patient who has any of the following features:
1. eye opening only to pain or not conversing (GCS 12/15 or less)
2. confusion or drowsiness (GCS 13/15 or 14/15) followed by failure to improve within at most one hour of clinical observation or within two hours of injury (whether or not intoxication from drugs or alcohol is a possible contributory factor)
3. base of skull or depressed skull fracture and/or suspected penetrating injuries
4. a deteriorating level of consciousness or new focal neurological signs
full consciousness (GCS 15/15) with no fracture but other features, eg
— severe and persistent headache
— two distinct episodes of vomiting
5. a history of coagulopathy (eg warfarin use) and loss of consciousness, amnesia or any neurological feature.
CT scanning should be performed within eight hours in an adult patient who is otherwise well but has any of the following features:
1. age>65 (with loss of consciousness or amnesia)
2. clinical evidence of a skull fracture (eg boggy scalp haematoma) but no clinical features indicative of an immediate CT scan
3. any seizure activity
4. significant retrograde amnesia (>30 minutes)
5. dangerous mechanism of injury (pedestrian struck by motor vehicle, occupant ejected from motor vehicle, significant fall from height) or significant assault (eg blunt trauma with a weapon).
In adult patients who are GCS<15 with indications for a CT head scan, scanning should include the cervical spine.
Indications for admission to hospital An adult patient should be admitted/observed to hospital if:
1. the level of consciousness is impaired (GCS<15/15)
2. the patient is fully conscious (GCS 15/15) but has any indication for a CT scan (if the scan is normal and there are no other reasons for admission, then the patient may be considered for discharge)
3. the patient has significant medical problems, eg anticoagulant use
4. the patient has social problems or cannot be supervised by a responsible adult.
Referral to neurosurgical unit A patient with a head injury should be discussed with a neurosurgeon:
1. when a CT scan in a general hospital shows a recent intracranial lesion
when a patient fulfills the criteria for CT scanning but facilities are unavailable
2. when the patient has clinical features that suggest that specialist neuroscience assessment, monitoring, or management are appropriate, irrespective of the result of any CT scan.
3. All salvageable patients with severe head injury (GCS score 8/15 or less) should be
4. transferred to, and treated in, a setting with 24-hour neurological ICU facility.
Children Initial assessment
Great care should be taken when interpreting the Glasgow Coma Scale in the
under fives and this should be done by those with experience in the management of the young child. Pediatric Glasgow Coma Scale and Scoring (for use in patients under five years of age)
Indications for referral to hospital In addition to the indications for referral of adults to hospital, children who have sustained a head injury should be referred to hospital if any of the following risk factors apply:
1. clinical suspicion of non-accidental injury
2. significant medical co-morbidity (eg learning difficulties, autism, metabolic disorders)
3. difficulty making a full assessment
4. not accompanied by a responsible adult
5. social circumstances considered unsuitable.
Indications for head CT scan Immediate CT scanning should be done in a child (<16 years) who has any of the following features:
1. GCS≤13 on assessment in emergency department
2. witnessed loss of consciousness >5 minutes
3. suspicion of open or depressed skull injury or tense fontanel
4. focal neurological deficit
5. any sign of basal skull fracture.
CT scanning should be considered within eight hours if any of the following features are present (excluding indications for an immediate scan):
1. presence of any bruise/swelling/laceration >5 cm on the head
2. post-traumatic seizure, but no history of epilepsy nor history suggestive –of reflex anoxic seizure
–amnesia (anterograde or retrograde) lasting >5 minutes
–clinical suspicion of non-accidental head injury
–a significant fall
–age under one year: GCS<15 in emergency department assessed by
–personnel experienced in paediatric GCS monitoring
–three or more discrete episodes of vomiting
–abnormal drowsiness (slowness to respond).
If a child meets head injury criteria for admission and was involved in a high speed road traffic accident, scanning should be done immediately
Indications for admission to hospital Children who have sustained a head injury should be admitted to hospital if any of the following risk factors apply:
1. any indication for a CT scan
2. suspicion of non-accidental injury
3. significant medical co-morbidity
4. difficulty making a full assessment
5. child not accompanied by a responsible adult
6. social circumstances considered unsuitable.
Referral to neurosurgical unit A patient with a head injury should be discussed with a neurosurgeon:
1. when a CT scan in a general hospital shows a recent intracranial lesion
2. when a patient fulfills the criteria for CT scanning but facilities are
3. when the patient has clinical features that suggest that specialist
neuroscience assessment, monitoring, or management are appropriate,
irrespective of the result of any CT scan.
4. All salvageable patients with severe head injury (GCS score 8/15 or less) should be transferred to, and treated in, a setting with 24-hour neurological ICU facility.
In hospital care All medical and nursing staff involved in the care of patients with a head injury should be trained and competent in the use and recording of the Glasgow Coma Scale. The GCS should not be used in isolation and other parameters should be considered along with it, such as:
–pupil size and reactivity
–respiratory rate and oxygen saturation
–unusual behavior or temperament or speech impairment.
Family members and friends should be used as a source of information.
Observations should be recorded on a chart
Children <3 years old who have sustained a head injury are particularly difficult to evaluate and clinicians should have a low threshold of suspicion for early consultation with a specialist pediatric unit.
Children who are admitted should be under the care of a multidisciplinary team that includes a pediatric trained doctor experienced in the care of children with a head injury.
Children should be observed on a children’s ward.
The risk of rapid deterioration is greatest in the first six hours after injury and then decreases. If the patient is admitted on the first day of the injury then repeat evaluation every few hours is indicated if high risk factors such as high energy injury, Glasgow coma scale < 15, or focal neurological deficit is present.
Medical staff should assess the patient on admission to the ward and should re-assess the patient at least once within the next 24 hours. Assessment should include: examination for the GCS, neck movement, limb power, pupil reactions, all cranial nerves and signs of basal skull fracture.
Any of the following examples of neurological deterioration should prompt urgent re-appraisal by a doctor:
–the development of agitation or abnormal behavior
–a sustained decrease in conscious level of at least one point in the motor or verbal response or two points in the eye opening response of the GCS score
–the development of severe or increasing headache or persisting vomiting
new or evolving neurological symptoms or signs, such as pupil inequality or
asymmetry of limb or facial movement.
If re-assessment confirms a neurological deterioration, many factors need to be evaluated but the first step is to ensure the airway is clear, and that oxygenation and circulation are adequate.
Clinical signs of shock in a patient with a head injury should be assumed, until proven otherwise, to be due to hypovolemia caused by associated injuries.
Whilst an intoxicating agent may confuse the clinical picture, the assumption that deterioration or failure to improve is due to drugs or alcohol must be resisted.
If systemic causes of deterioration such as hypoxia, fluid and electrolyte imbalance, or hypoglycemia can be excluded, then resuscitation should continue according to accepted trauma protocols.
After traumatic brain injury, agitation may be a sign of neurological deterioration, hypoxia, electrolyte disturbance, drug/alcohol withdrawal, or seizures. Medical evaluation should be done in conjunction with pharmacological therapy for behavior.
Therapeutic Goals and Interventions
Systolic BP < 90 mm Hg and O2 Saturation < 90% should be avoided.
Mannitol in doses of 0.25gram/kg to 1.0gram/kg may reduce ICP. Our usual regimen is to give an initial dose of 1.0 gram/kg and the start 0.25mg/kg every 8 hours. The dose can be increased up to 1.0 gram/kg and frequency up to every 6 hours as needed. It is most useful as a temporizing measure such as to treat a patient suspected of having a mass lesion which may be surgical while preparing that patient for surgery. It is most effective in bolus doses rather constant infusion which may be repeated every 6 hours. Most of the world wide experience deals with controlling intracranial pressure which is being monitored. It should not be a part of routine head injury management. Side effects of hypotension, increases in size of intraparenchymal brain hemorrhage, and kidney dysfunction may occur.
The use of mannitol for head injury treatment in developing countries without ICP monitoring has not been well studied.
1. Salvageable Head Injury with GCS 8 or less.
2. Deterioration from GCS > 8 to less for three days as above
3. Pre-operative .25gram/kg to 1.0gram/kg dose for suspected or known mass lesion. May be repeated intra-operatively.
4. Post-operative management of cerebral edema
Enteral feeding should be begun by 72 hours after injury. Hyperglycemia should be avoided as increased intracellular lactic acidosis can worsen brain injury.
Seizures and Seizure Prophylaxis
Prophylactic anticonvulsants does not reduce late seizure development or improve outcomes. However we face an unusual situation in Ethiopia where there are no intravenous anticonvulsants. We have had experiences of a few patients in the past few years whose developed early onset post traumatic seizures which where difficult to control while we were waiting for oral phenytoin to be absorbed which typically takes about 24 hours. Therefore we are changing our previous recommendation to start phenytoin or carbamezipine in any patient with an abnormal brain finding on CT Scan of the brain and continue for 7 days.
Anticonvulsant treatment indications:
Phenytoin use according to body mass and age for a seizure in the first few days and continued for one week.
Craniotomy for intraparenchymal lesion (evacuation of hemorrhagic contusion or lobectomy) or if a dural tear is discovered such as for depressed fracture
Routine single dose of Ceftriaxzone 1 gm IV on call for adults and 50mg/Kg in children for closed head injuries requiring surgery.
Single dose of periprocedural antibiotics for intubation only unless the patient has signs of aspiration pneumonia already present.
Low molecular weight heparin is contraindicated in the presence of acute head injury. If there is no large hematoma (intraparenchymal) then generally should wait at least five days before beginning low dose heparin 5,000 units BID or low molecular weight heparin Graduated stockings or pneumatic compression stockings if available are appropriate.
Profound hypercarbia may increase ICP and profound hypocarbia may decrease cerebral perfusion. Hyperventilation is to be avoided in the first 24 hours after injury. Temporary mild hyperventilation pre-operatively or intra-operatively may be used.
There is no sound scientific evidence supporting the use of steroids for head injury.
Under special circumstances such as post-operative swelling or diffuse cerebral swelling in a viable patients in consultation with neurosurgical staff pentobarbital at 3mg/kg/ hour may be given for up to three days to attempt to control brain swelling. Patients who have bilateral dilated pupils and decreased brain stem function are not candidates for this treatment modality.
Most of the studies suggest post-traumatic meningitis can be treated similar to community acquired bacterial meningitis with Ceftriaxzone 1 gm Q12h in adults. If no response is seen consideration can be given to adding Vancomycin and Meripenum for resistant organism. In our experience most patients respond to a 10 day course of Ceftriaxzone. Consideration can be given to performing a lumbar puncture for culture and sensitivity if CT Scan shows no mass effect. If staph aureus is identified then treatment should be extended for 21 days duration.
Surgical Management Guidelines
Note: The clinical progression of the patient must always be considered strongly in decision to do surgery or treat conservatively. Lesions affecting the temporal lobe area are at high risk of rapid deterioration especially within the first three days after injury.
–An epidural hematoma greater than 30 cm squared should be evacuated regardless of GCS score
–An epidural hematoma less than 30 cm squared, midline shift less than 5mm, and thickness less than 15 mm in a patient without neurological deficit can usually be considered for nonsurgical treatment if clearly clinically stable
–Acute epidural hematoma is best treated by craniotomy rather then burr holes. Tacking up of the dura to prevent rebleeding should be done.
Acute Subdural Hematoma
–An acute subdural hematoma with a thickness greater than 10 mm or midline shift greater than 5 mm should be evacuated regardless of GCS score
–Patients who have a large parenchymal contusion and acute subdural less than 10mm with an admission GCS< 9 and then subsequent deterioration may be a candidate for surgery.
–In severe cases of brain swelling. Bone flap removal and duraplasty may be necessary.
Surgery for Traumatic Intraparenchymal Lesions
–Surgery for resection of intraparenchymal lesions is not within the normal procedure guidelines for general surgery.
–Patients with focal intraparenchymal lesions who present with a GCS of 8 will be initially placed on medical management protocols.
–Patients with a GCS of 8 who deteriorate despite medical management will be discussed with the neurosurgical staff as regards to management
Chronic Subdural Hematoma
–A totally asymptomatic patient with evidence of a chronic subdural hematoma may be conservatively followed
–A symptomatic patient with chronic subdural hematoma should undergo timely operation
–The best outcome in chronic subdural hematoma was found in a prospective study utilizing the two burr hole technique with subdural drain placement. At Ayder an initial burr hole will placed frontally or parietally depending upon where the greatest thickness of the hematoma is found. If after irrigation of the subdural space the brain does not expand to the dura then a second burr hole will be placed. If the clot is gelatinous then the burr holes will be converted to a craniotomy. A pediatric feeding tube will always be place in the subdural space at least one centimeter beyond the proximal last side hole and exited through a separate stab wound.
–The subdural drain may be removed when the old blood drainage converts to CSF. The drain should be removed by the morning of the third day after surgery.
–After surgery while the subdural drain is in place the patient’s head should be kept flat to maximize brain re-expansion which will push out the remaining subdural hematoma
–If patient deteriorates following surgery after initial improvement or fails to improve then consideration for a repeat CT scan should be done.
Closed Depressed Skull Fracture
–Patients with a closed depressed fracture with a depression less than 1 cm and no neurological findings or associated hematoma requiring surgery are potential candidates for conservative treatment
–A closed depressed fracture with a depression 1 cm or greater (which is deeper then the inner table) and/or neurological deficit should under go timely surgical intervention.
–Patients with simple depressed fractures without dural tear or cerebral contusion require only routine pre-operative antibiotic prophylaxis and no anticonvulsant prophylaxis.
Open Depressed Skull Fracture
–Patients with an open depressed fracture greater than the depth of the calvarium should undergo surgery.
–Operation should be done within the first 48 hours after injury to reduce the risk of infection.
–The bone flap or fragments should be cleaned with betadiene and saline thoroughly before replacement
–A water tight closure of the dura should be attempted..
–Debridement of nonviable and contaminated brain should be done.
–A 24 hour course of intravenous Ceftriaxzone and Metronidazole should be given for cases where there is only minimal contamination and the dura is intact. Patients will then receive a 7 day oral course of Amoxicillin and Clavulanate (Augmentin) 500 mg every 8 hours for adults.
–An 7 day course of intravenous Ceftriaxzone and Metronidazole should be given for cases where there is extradual purulence, gross contamination or penetration of the brain especially if surgery was delayed more than 48 hours after injury.followed by a one week course of Augmentin orally.
–Post traumatic cerebritis or abscess requires 6 week course of intravenous antibiotics.
–Anticonvulsant prophlaxis should be given to all patients with dural laceration and open brain injury.
The academic new year at Mekelle University for residents (doctors who have graduated from medical school and now will undertake several years of specialty training) is just a few weeks away. They will transform from the theoretical and observing from the sideline to actually being involved in medical care to improve the quality and longevity of their patients. A part of the new experience will be their discovery that there is a limit of resources even in the richest countries and of course more severe in the developing countries. This same thing is happening not just in Mekelle, not just in Ethiopia, but around the world in all the teaching hospitals.
Although we like to pretend otherwise there is no escaping the inevitable fact that we are mortal and will at some point suffer significant illness followed by death. An Ethiopian diaspora calculated based upon the year 2000 that the per capita lifetime medical expenses where $316,000 in the state of Michigan (USA). Most of the cost occurs in the first year of life and after age 50. Women were more than men because they live longer. About one third occurs in middle age and about one half in the senior year of life.
It is hard to put a measure on the value of human life.
When discussions occurred about the use of dialysis as to whether should be payed for by government, analysts determined that spending $50,000 to give an additional year of quality life was worthwhile. This same measure was applied by several governments world wide. The actuarial value of a human life in developed countries is put somewhere between $ 500,000 and ten million dollars by actuarial experts. It is much less in developing countries where the economic output of an individual is much lower often less than a few hundred dollars a year.
The most recent budget for healthcare in Ethiopia was 1.4 billion dollar equivalents which cames out to about $14 per person for the approximately 100 million Ethiopian population. If you count out of pocket expenses it increases to about $24 per capita. This is of course much less than than the $4000-$5000 you see in European countries and the almost $10,000 in the United States. Yet even in these rich countries there are cries that funding is insufficient.
This means that physicians and the policy makers whom they advise have to learn to do more with less. They have to spend resources where they will have most impact. How are these decisions made? Medical ethicists talk about years of productive life as a reasonable way to compare, for example, spending money to help newborns versus the elderly. But not all cultures would agree with this concept totally. There is often a belief that older citizens should be rewarded for their service to society. Note the creation of Medicare and Social Security and its equivalents in the United States and many other developed countries.
Good medical care even in this age of limits is possible. It requires a sound knowledge of likely outcomes, compassion, and realistic communications with the patients and the community at large in both developing and developed countries. The inevitable consequences of our mortality and economic reality of limits leaves no room for anything other than truthful sincerity.
Given the already highest incidence of neural tube defects measured globally present in Ethiopia it would seem exceedingly urgent to immediately call for the cessation of use of Valproic acid, which has been shown to cause neural tube defects, in women of child bearing age in Ethiopia except for special circumstances.
History of Valproic Acid
Valproic acid was first produced in 1882. At that time its discoverer did not imagine that would be any therapeutic use because it was thought to have no pharmacological value. Then in the 1960s it was begun to be used in France and then in the late 1970s was approved for use in the United States as a primary drug for first epilepsy and then also for migraine headaches as well as mood disorders.
Over the next thirty years, however, concerns began to be raised about the potential relationship of the drug and birth defects. Both a joint European study and a separate French study showed that women of child bearing age taking appropriate therapeutic doses of 1000 mg a day or more had a high incidence of neural tube defects and other malformations up to seven times higher than the control population.
Valproic Acid Use in Ethiopia
The use of Valproic acid is relatively new in Ethiopia in just the last few years. A review of the treatment of epilepsy from Gondar University showed that 4.84 % of patients were using it. In addition it is being used to treat mood disorders and migraine headache to an unknown extent. The prescription of this medicine is relatively unrestricted and can be done by general practitioners and even non-physician health care providers. Unfortunately the official formulary for Ethiopia briefly mentions that pregnancy is a contraindication and suggests consideration for folic acid supplementation should be given to reduce the risks of birth defects. However a recent animal model study using chick embryos showed that supplemental folic acid for neural tube defects caused by valproic acid was not effective in prevention.
Neural Tube Defects in Ethiopia
Our research at Mekelle University looking at the incidence of neural tube defects in the Tigray region of Northern Ethiopia suggested an over all incidence of at least 130 per 10,000 births but with some locals reporting close to 300 per 10,000 births. We know from studies done by the Ethiopian Institute of Public Health that 28% of women of children bearing age throughout Ethiopia have a significant folic acid deficiency which is likely the strongest contributing factor to the high incidence of neural tube defects
Recommendations for Valproic Acid Restriction in Ethiopia
1.Given the already highest incidence of neural tube defects measured globally present in Ethiopia it would seem exceedingly urgent to call for the immediate cessation of use of Valproic acid in women of child bearing age except for situations where no other drug can be used and the patient is receiving implantable or injectable forms of birth control.
2. Prescription of Valproic acid should only be done by physician sub-specialists in neurology, neurosurgery, or psychiatry and should require extensive counseling to the patient.
3.The formulary of Ethiopia should be modified and vigorously amended to warn of the risks. Although consideration for folic supplementation is appropriate it should be clearly stated that such supplementation may not be effective in preventing birth defects.
Traditionally surgery for hydrocephalus has been performed by neurosurgeons who undergo vigorous neuroscience basic training and supervised surgical experience of at least 5 years in length (longer in developed countries) after medical school. Recently there has been some discussion as to whether in African and other undeveloped countries general surgeons should be taught to perform ventriculoperitoneal shunts to treat hydrocephalus. The treatment of hydrocephalus should remain under the direction and in the hands of neurosurgeons.
Hydrocephalus as a medical condition has been recognized since the time of the ancient Greeks. The concept of surgery to treat hydrocephalus by diverting the flow of cerebrospinal fluid began in 1949, when Nulsen and Spitz implanted a shunt successfully into the caval vein with a ball valve. Between 1955 and 1960, four independent groups invented distal slit, proximal slit, and diaphragm valves almost simultaneously.
An estimated 750,000 people have hydrocephalus, and 160,000 ventricular peritoneal shunts are implanted each year worldwide almost always by neurosurgeons. About 56,600 children and adolescents younger than age 18 years have a shunt in place.
The incidence of hydrocephalus in Africa is estimated to be 145 per 100,000 which is three times higher than in the developed world. Thousands of these children will need surgical intervention, either ventricular peritoneal shunt or the newer, but still not clearly accepted as superior, endoscopic procedures.
A survey conducted among African neurosurgeons in 1998 showed that there were 500 neurosurgeons in Africa; that is, one neurosurgeon for 1,350,000 inhabitants, and 70,000 km2. That number is significantly increased now but the exact current number is unknown. Worldwide the average is 1 neurosurgeon per 230,000 but in Africa it can be as low 1 per 9 million people. It is believed there are 700 neurosurgeons currently or about 1 per 1,238,000 people which is an improvement but still not nearly enough. Ethiopia currently has about 30 practicing neurosurgeons and will soon be graduating about 30 newly trained neurosurgeons per year. This means Ethiopia will need about 450 functioning neurosurgeons taking into account expected population growth.
Although the training of neurosurgeons in performing ventriculoperitoneal shunts has become somewhat standardized via the World Federation of Neurosurgical Societies as well as international neurosurgical groups, the training of general surgeons to do this procedure has not been rigorously studied. There are very few publications about the results of general surgeons performing ventriculoperitoneal shunts but an a study from Kenya done in 2010 showed a significantly high complication rate of 65% with an infection rate of 9.1% and shunt malfunction rate of 11.1%. This was much different than reported by Dr. Warf , an American trained neurosurgeon who created a specialized center in Uganda, with a malfunction rate of 4%.
More recently endoscopic procedure to open the third ventricle to the cistern and coagulate the choroid plexus are gaining ground but not totally proven yet. These procedures clearly require specialized training and knowledge of anatomy of the caliber of a neurosurgeon and not a general surgeon.
The real issue was not really the shortage of surgeons but the bottleneck was lack of hospitals, operating rooms, and clinics. Additionally transportation to get healthcare is a real issue. Now Ethiopia has seen the light and has three training programs for neurosurgery in Ethiopia and are graduating about 30 per year. Again the problem is we have more surgeons than facilities to operate in.
African governments will see the idea of adding shunt placement to general surgery as an easy fix. In reality they are already overworked. I have taught medical students and general surgery residents. Many people think ventriculoperitoneal shunts are the easiest procedure but I always tell my neurosurgery residents and fellows it is not. Decisions about when to shunt, is the shunt working, is it infected? require experience and training. Academic following of outcomes, techniques, epidemiology requires an academic neurosurgery program take the lead.
Unfortunately there is no shortcut to capacity building. We are now training neurosurgeons for other African countries as well as Ethiopia. Eventually we will need more than 450 which will take time.
Finally I would say that our approach to hydrocephalus is changing rapidly. For us and the Uganda group we are consistently reducing the number of shunts we are doing each year. Whereas in the past we did nearly two hundred it is now going to be less than 100 even though we cover 20 million plus population with the highest myelomeningocoel rate in the world. We now recognize that many neural tube defect newborns have low grade infections which require antibiotics sometimes over 21 days until the csf is clear. Many times their hydrocephalus stabilizes after a few fontanelle taps. Although the post infectious group is rising ( we are in the infamous meningitis belt of Africa) similar we have avoided shunting by similar close follow-up. Our shunt infection rate is currently 3% because we identify these chronic low grade infections. I shutter to think what would happen if general surgeons with little experience are let loose upon this situation.