The brave nonviolent defense of Ayder Hospital by Mekelle citizens a year ago

Men and women Mekelle citizens of all faiths put up roadblocks to prevent looting of Ayder Hospital in November 2020 (Photo from Eritrea Hub)

This is the story I witnessed of the brave unarmed civilians peacefully protesting and blocking invading forces from ransacking Ayder Comprehensive Specialized Hospital in Mekelle, Ethiopia in November of 2020. I had been performing neurosurgery, teaching fellows, and medical students at Mekelle University  in the Tigray region of Ethiopia since 2015 in a federal university and hospital.  As such I was present in Mekelle from the onset of the war between the Tigray Defense Force and the Ethiopian/Eritrean forces from the onset until my evacuation about 3 months later at the behest of international influence and my family which was three days of driving through multiple checkpoints and unstable areas until we finally arrived in Addis Ababa.

The day before the occupation of Mekelle we knew that the Tigray Defense Force had left the city in hopes to avoid civilian casualities. Yet early in the morning an artillery barrage started which targeted essentially the whole city. Rounds were landing about every 5 seconds. This lasted until the early morning hours of next day. Stopped for a while and then was restarted for several hours. In my own immediate neighborhood just a few blocks from the Mekelle University hospital, Ayder Comprehensive Specialized Hospital many homes and buildings were destroyed and many killed. A market and home for elders was directly hit killing and wounding many.

About 200 yards from my house, a home that housed a large extended family suffered a direct hit that sent shrapnel breaking my windows at about 6:30 in the morning. I ran over there to find a young woman in the street with a severe bleeding wound in upper leg but that was just the beginning of the horror. The walls of the house had been destroyed on two sides and the rest looked like a Swiss cheese with many perforations. On the ground was a motionless young woman who had only a red spot on the ground where her chest was supposed to be. Her lifeless arms were extended with each one holding toddlers. The children where crying. When I pulled back their hair I found that hundreds of small munitions fragments had penetrated the scalp of both children although the eyes seemed okay. There was nothing we could do for the mother nor her mother who lay beside her dead as well from penetrating shrapnel. Remaining family members rushed the sister with the injured leg and the children to Ayder Comprehensive Specialized Hospital. 

At the hospital emergency room there was wave after wave of ambulances and private vehicles bringing those hit by the attack who were all civilians. Some could be helped but many were beyond hope. We were able to save the children and their aunt from the attack near my house. Although we would sometimes previously do mass casualty from bus accidents in the past this was a much greater magnitude as we saw more then 120 patients in the first few hours. 

Before the invasion of the city, we had been receiving civilian causalities,  Tigray Defense Force causalities, and also Federal/Eritrean causalities. We treated them all the same. The local people even brought food and blankets for the all the groups. However after the invasion the tenor of the invading force changed. Many patients were just suddenly whisked away to parts unknown and we were not allowed to inquire.

As the invading forces approached we saw many women with vulgar mutilations of their vagina, amputations, facial injuries, and mortal wounds from gunshot and blades. There were women shot in back apparently running from invading Eritrean and Ethiopian forces. Sometimes their small children were brought in with partial decapitation.

The next day on November 26, 2020 at which time Federal Ethiopian armed forces and Eritrean forces invaded unopposed the city of Mekelle.  For the next few days in Mekelle there were Ethiopian and Eritrean forces looting, shooting, robbing, and harassing civilians all around the Ayder area where I lived and the hospital was located. The hospital was occupied by Ethiopian army regulars, then Special Forces from Oromia, and so-called Federal Police. These fighters would be in every room watching everything done by nurses and doctors. They told us to write in the medical records that any civilian injuries were caused by Tigray fighters and not by Ethiopian or Eritrean forces. Then suddenly for about half a day they disappeared.

Rumors where flying in the city that Eritreans where ransacking public utilities, schools, etc. The hospital had always been a source of pride and necessity for not only Mekelle but all of Tigray. The local population of civilians began to put tires, logs, and stones to block trucks or other vehicles in the streets surrounding around Ayder Comprehensive Specialized Hospital, the main teaching and tertiary hospital for Tigray, fearing that the hospital which was highly valued by the city would be destroyed or looted. Special Red caped soldiers showed up and began harassing the locals more and more. 

Among the first to call citizens to action was the muazzin of the Adishmdhun Mosque. Although there was no electricity in the city using the mosque generator and microphone he called people to guard the hospital. The message was ” to all residents of Mekelle be Muslim, Christian, males or females : Ayder is being looted, so go and protect your hospital “. Immediately the people began to make the gatherings. There was was a group of motorcycle men who tended to gather at a pub just a few blocks from the hospital who began calling the same thing using a speaker. Youth groups and community elders answered the call. The demonstration and blocking of the roads was done with people of all faiths and different ethnicities.

The locals did not back off. They gathered by the thousands and began to surround the hospital 24 hours a day. Many times semitrucks and smaller trucks driven by Eritreans which were empty tried to make it to the hospital to loot it but where physically blocked by protestors standing in their way.  At one point a group of young men were shouting about ten feet in front me to the soldiers. Suddenly the soldiers fired at them killed one and injuring two others. At that time there were tires burning all around the hospital with thousands of protesters. The soldiers were scared and I feared the worst was going to happen. It was tense until morning. Finally the lined up trucks driven by plain clothed Eritreans were told to leave by the invading forces. The two that survived to be treated were hauled off from the hospital by the invading forces and have not been seen again as far as I know.

Pictures I had of the event were erased by Eritrean patrols that would search me everyday I went to the hospital but I will never forget the bravery of the people in Mekelle who unarmed defended their hospital. 

Ethiopian intentional punitive defunding and diversion of Tigray medical supplies

Ayder Comprehensive Specialized Hospital campus of Mekelle University

Intentional starvation and complete blockade of medical supply are primary strategies of the Ethiopian government towards the Tigray state in violation of not only moral propriety but also international law. How this unfolded will be told in this writing.

In discussion with displaced and in place faculty of Mekelle University this week I have learned that Ayder Comprehensive Specialized Hospital has more than 60 infants and children dying of starvation in the hospital averaging 2 or more deaths per day. Today there is no medicine, no nutritional supplements, no baby food or bottle formula, no laboratory, no x-ray, and the staff is all working voluntarily without pay. Every day children and adults are dying of simple treatable acute and chronic conditions such as hypertension, diabetes, childbirth, pneumonia, and accident just to name a few.  This intentional complete abandonment of the Ethiopian government’s responsibility to care for innocent noncombatants is a violation of international treaties and the Genocide Convention of the United Nations to which Ethiopia is a signatory. 

I previously published that we now can accurately estimate that the crude death rate, that is the number of expected deaths per 1000 population per annum will raise from its pre-war level of 6 by %500 to 32 (its level in 1950 when there was almost no health care) meaning over 228,000 people will die in Tigray each year due to complete lack of health care.

For the previous year while the Ethiopian, Eritrean, and Amhara regional governments were planning their invasion of Tigray there was also a plan to defund Mekelle University with reduction and stoppage of many routine payments such as for a routine repair of the MRI scanner and CT scanner.

Then following the Ethiopian Eritrean occupation of Mekelle in late November 2020 the medical supply, maintenance support, and even communication with Ethiopian Ministries of Science and Higher Education and Health were gradually completely cut off to the federally funded Ethiopian Mekelle University and it’s referral and teaching hospital Ayder Comprehensive Specialized Hospital.  

The acting President of Mekelle University, Dr. Fetien Abay, and Chief Academic Head of the College of Health Sciences, Dr. Hayelom Kebede,  went to see the military commander of the Ethiopian occupying forces in early December when the hospital’s supplies were already near exhaustion at Planet Hotel. He told them that the Ethiopian military and government had no responsibility to care for the civilian population. Subsequent discussions with Mulu Nega, the first appointed governor of the Tigray Interim Administration appointed by Prime Minister Ahmed to preside over the occupation, and then the Eritrean Abraham Belay, long time supporter of Isaias Afwerki, dictator of Eritrea and now the defense minister for Ethiopia who replaced  Nega he was too “lenient”. Communications with Belay were that Ethiopia had no responsibility to offer any civilian support or assistance because civilians were not supporting the Ethiopian government.

Since the occupation and extending even up to the recent few months intermittent conversations with Dr. Lia Tadesse by Dr. Hayelom  Kebede and others have proven failures. She has expressed regret in telephone conversations that she is not allowed to take any action to supply Ayder Hospital or the Tigray Regional Health Bureau because the Prime Minister has forbid it.

Almost two years ago I was consulting with a group working with multiple international nongovernmental organizations to propose a plan to help improve the function of Ethiopian government purchasing. This included discussions about joint ventures on producing medical consumables in Ethiopia. The plan was rejected after our presentation to the Ethiopian Investment Commission because the funder of a factory wanted to build it in Tigray. Out of this work came a discussion with high officials of the Korea Hospital that they had tried a similar goal  before and discovered that Ethiopia was selling some of the supplies it purchased at discounted price or partially subsidized price to other African countries at higher prices to get “hard currency”. It now appears that some supplies that were collected and meant to be shipped to Tigray since the onset of war may have been just given to Eritrea or instead sold as means to collect hard currency.

What happened to captured Tigray fighters and the injured ENDF Oromia fighters?

The TDF is caring for thousands of ENDF, FANO, and Oromo POWS in rehabilitation camps

What happened to injured Tigray POWs and injured Oromia soldiers fighting in Tigray before the reoccupation of Tigray by the TDF(Tigray Defense Force)?

You hear a lot of news and see many videos of captured ENDF(Ethiopian National Defense Force) and Amhara fighters now in TDF custody but what happened to Tigray fighters captured by the ENDF and Eritreans?

I was at Ayder Comprehensive Specialized Hospital through the beginning of the war continuing to the beginning of January 2021 and I have been trying to investigate where this prisoners are located. We know that the Ethiopian and Eritrean government had planned a major assault on Tigray from some time before the events of November 4th 2020. The government had lined up casualty treatment hospitals with volunteer doctors mostly from Addis Ababa University to be based at Woldia during the major assault on Tigray and ending in Mekelle.

During the first two weeks of the war we treated civilians, Tigray Defense Forces soldiers, Ethiopian National Defense Soldiers, and Eritreans at Ayder Comprehensive Specialized Hospital. A short time after the occupation of the city of Mekelle, the military commander of the the Ethiopian occupying forces decided to move injured ENDF and Eritrean fighters to a new military hospital that had just been constructed recently. This went on for a few weeks. The Red Cross showed up soon upon the start of the conflict and we wanted them to collect information on all injured persons but they were turned away by the Ethiopian authorities.

Medical supplies to Ayder Hospital and the military hospital essentially ceased and the Ethiopian military decided to treat their casualties in an open air hospital constructed in the newly built football stadium near the Martyrs Museum which was serving as the commanding generals headquarters.

After this the story of what happened gets difficult to follow. Many Amhara patients were transferred out of Tigray to Amhara hospitals including Woldia but not everyone.

There is a rising story that preferential treatment was given to Amhara FANO fighters and Ethiopian National Defense Forces while Oromo soldiers who were thought to be “poor candidates to survive” received less care and where often allowed to die.

Additionally most to the Tigray Defense fighters as well as many civilians including rape victims of the invading forces were removed from Ayder Hospital as I and other witnessed and never to be seen or heard from again. At this time there are no reports of any Tigray POWs in any hospital anywhere. Most of the photos given to the Ethiopian press labeled as Tigray POW have not been fighters but college students detained, Tigray residents from Addis Ababa, and refugees returning from Saudi Arabi.

It has recently been reported by several sources that some detainees of this group were summarily executed without any legal proceeding.

The question remains where are Tigray POWS? Where are the Oromia fighters injured that were fighting in Tigray?

Remembering 300 days of sorrow and strife in Mekelle

300 Days ago the misery of Tigray began but now the Tigray Army is giving hope for 7 million suffering in Tigray

Beginning 300 days ago Mekelle University has suffered airstrikes, artillery bombardment, rifle fire, pilfering of its records and equipment. Today the halls of the university and the wards of its hospital are empty accept for refugees trying to survive. Many of our employees and staff have been killed not because they became fighters to defend Tigray but just for walking on the street or trying to evacuate their elderly parents from a village.

The whole of the city of Mekelle, capital of Tigray, was bombarded with artillery for 24 hours even though all TDF defenders had left the city

A year ago Mekelle University was teaching thousands of students from not only Tigray and Ethiopia but many surrounding countries. Ayder Comprehensive Specialized Hospital was teaching medical school to hundreds and training specialists in pediatrics, internal medicine, general surgery, pathology, obstetrics gynecology, otolaryngology, oral maxillofacial surgery, orthopedics and trauma surgery, forensic medicine, and neurosurgery. We were starting training in master anesthesia, MD anesthesiology, oncology, neuroscience PhD, and many other fields. Leading research was done in agriculture, veterinary medicine, engineering, medicine, and many other fields.

Even though we were a “Federal University” we were abandoned by the Ministries of Science and Higher Education as well as the Ministry of Health. As soon as the war started they pretended we did not exist. The Mekelle community shared what little food, water, and shelter they had with students from other regions and countries. All payment stopped to employees. All medical supplies stopped. With the encouragement of the the Ethiopian military Eritreans were allowed to rape students, ransack buildings, and take any war booty meaning computers, lab equipment, etc.  back to Eritrea.

It will take millions of dollars to rebuild the University and its services to the community. Unfortunately is is just a small part of the overall damage done to Tigray. Millions are still starving at the order of Abiy Ahmed and his hench man Isaias. But I can imagine it would be far worse now if the Tigray Army had not resurged and marched forward. It is not over but we pray God will guide them on their mission to find peace and eliminate the threat to the Tegaru from their man-made insufferable misery.
Psalm 18:39
“For You have girded me with strength for battle;
You have subdued under me those who rose up against me.”

What I learned and hope to return to at Mekelle University Ayder Comprehensive Specialized Hospital

Ayder Comprehensive Specialized Hospital campus of Mekelle University

In building neuroscience and neurosurgery at Mekelle University I experienced great happiness in serving the people and training future neurosurgeons and scientists.  My seven year experience at Mekelle University serving the people of Tigray and surrounding areas as well teaching neurosurgeons and neuroscience gave me a new perspective on what is true career success. I now recognize there are three phases.

When I first came to Ayder Comprehensive Specialized Hospital in 2015 my initial goal was get a good neurosurgery service going. They were really the only government hospital capable of developing this goal outside Addis Ababa, the capital of Ethiopia, as well as being some distance north so it would offer chances to treat patients who would otherwise go untreated. The University and hospital were committed to building not only quality and quantity of good health care for Tigray and surrounding regions but also to medical education. 

Initially I helped teach neuroscience and clinical neurology/neurosurgery to medical students and general surgery residents (young physicians who have graduated from medical school now doing specialty training) basic neurosurgical skills involving mostly traumatic injuries. My goal was to create a neurosurgery training program as well as a neuroscience research team. 

Teaching medical students about head injury

After about a year working with Ethiopian Ministries and some good collaboration from the Ethiopian ministries, World Federation of Neurosurgical Societies, and Mekelle University faculty we started a five year training program and a three year fellowship program. Up until the Tigray Ethiopian conflict we had grown to 18 trainees, doing 1,500 operations  year, and published internationally recognized research with our multidisciplinary research team on neural tube defects which occur in a high incidence in Ethiopia.

Our research team meet with the World Health Organization

Going through this experience made me reflect on what has been important in my career. When I was a college student at Texas A&M, then a medical student at Harvard, and finally a resident at the University of Miami I was mostly focused on personal achievement and perhaps also personal recognition. Through out that experience and subsequent practice I saw my career as having two phases. Learning to be a neurosurgeon and then becoming a great neurosurgeon. However it was my experience at Mekelle University and Ayder Comprehensive Hospital that taught me there was still a greater accomplishment which was to train great neurosurgeons and neuroscientists. 

Senior neurosurgery resident is supervised to remove a brain tumor

At first it was struggle. The hospital had little experience with neurosurgery. As a 60+ year old guy I was in the hospital every night doing surgery with young general surgeons and then residents with whom we had to start from scratch. Still they were eager to learn. With help from Indian and the few Ethiopian neurosurgeons we got up to date textbooks for them to read. Even though English was their second language they became proficient. At the end of the first year they knew more than I did at their level some 40 years ago. 

During surgery they have to learn about anesthesia, positioning, hand control, to make movements less than millimeter which could mean life or death, how to control bleeding, how to do a 12 hour operation, and much more. We began to have weekly seminars on very complicated ideas where they absorbed the concepts so well I was learning as much they were.  We were organized as most neurosurgical services in a sort of military style hierarchy to which the residents responded to well. Very quickly good and close relationships developed not only with those that were Tigray but also with others from other Ethiopian regions and other countries in the program.

I formed strong relationships with the research bodies of Mekelle University and we created a strong multi-disciplinary research team on neural tube defects which lead to meeting with government and World Health Organization officials, international NGOs, and a finally the beginning of a nationwide plan for prevention and treatment.

Before the  Ethiopian occupation and blockade shut the neurosurgery training program down we had operated on more than 5,000 patients from not only  Tigray but also Amhara,  Eritrea, and occasionally Addis Ababa to Gambella. This week far away from Mekelle I had been doing the “paper work” for my first graduates. I wish we could have had a formal ceremony but I had good voice communication provided. Now I have learned that the best phase of a neurosurgeon’s career is seeing his trainees carry on and expand what I started. 

Holiday dinner with my neurosurgery residents and fellow

I pray God will see fit to facilitate Ayder Comprehensive Hospital and myself to return  to its service, teaching, and research missions once again.

Ethiopia has committed genocide and turned Tigray into a concentration camp

The government of Ethiopia while claiming a law enforcement operation has committed genocide to the people of Tigray and turned Tigray into a concentration camp.

What is the definition of a concentration camp?
According to the highly respected encyclopedia Britannica a concentration camp is “defined as an internment centre for political prisoners and members of national or minority groups who are confined for reasons of state security, exploitation, or punishment, usually by executive decree or military order”. What the Ethiopian government has done to the Tegaru, Irob, Agaw, Kunami, Afar, Orthodox, Catholic, Christian, and Muslims who live in Tigray meets every requirement stated in this definition of a concentration camp and in every way just a deadly as those recalled from previous examples when evil predominated a society.

Actions of Ethiopia against Tigray are more than law enforcement
When the Ethiopian National Defense Forces and Eritrean Army units invaded the Regional National State of Tigray in November 2020 the leadership of Ethiopia specifically stated that was being undertaken was a law enforcement action to capture the leaders of a “terrorist group”, Tigray People’s Liberation Front (TPLF), and that there was no intent to take action against the civilians of Tigray. In fact they explicitly stated they were proceeding with this invasion to not only capture the leadership but also to protect the security and life of their “brother” Ethiopians.

At the time of invasion I was Chief of Neurosurgery and on the faculty of Mekelle University, a federal university not under the Tigray state, which had medical students and specialty trainees from almost every regional state in Ethiopia as well as surrounding countries. Additionally it administered Ayder Comprehensive Specialized Hospital which served a population of about 10 million including not only Tigray but also Afar, northern Amhara, and recently even Eritrea intermittently when the border was open. Additionally we occasionally cared for patients from Addis Ababa and the SNNP (Southern Ethiopia).

Following the complete take over of Tigray we were initially told by the Interim government and military commands that the government, medical, and educational services would be quickly restored. But instead they quickly deteriorated well before the reorganization and re-emergence of the Tigray Defense Forces. Except for a very short time of a few weeks early on the  following have been cut-off and never restarted including banking services, electricity, telephone and cell, internet, water, civil infrastructure management, hospital supply, schooling, etc.

Although the Federal government claimed it was giving 70% of the trickle of very basic aid that was coming in reviews by well established international authorities revealed it was less than 3% of the total which was in itself dramatically less than required.

Soldiers of the Ethiopian Army even took videos celebrating the killing of civilians

As the weeks progressed the undeniable evidence was increasingly seen that sexual abuse of women now estimated to be in the thousands, extra judicial killing of whole villages, routine execution of males even those below or above that generally considered to be militarily capable were reported even by the Ethiopian Human Rights Commission. Although there may be a possibility of some actions by Tigray militia which also require investigation the exponentially greater magnitude affecting hundreds of thousands of violation of human rights and killing by soldiers under the direct command of the Ethiopian government cannot be denied. If not stopped the number being threatened will rapidly accelerate to millions.

More than 350,00 people are at critical levels of starvation now and will increase rapidly

Instead of taking corrective action to improve the humanitarian situation which would possibly yield the benefit of making the civilian population of Tigray more peaceful instead new arguments surfaced from mouthpieces of the Prime Minister’s advisors that due to previous claims of unfair treatment by the TPLF that justified the violations of human rights currently underway. Videos emerged stating that every Tigray should be killed at birth. Eritrean and ENDF soldiers have stated to neutral third parties that they were instructed to rape women to destroy the chance for Tigray to have children.

The Nejashi Mosque was bombarded and then ransacked

Religious institutions, artifacts, and worshipers were targeted for destruction which had nothing to do with a “law enforcement” action. One of the most important Mosques in the world in Negash where the followers of Mohammed took refuge from prosecution from pagan Saudi rulers at the invitation of a Christian king was intentionally bombed and ransacked. What does that have to do with “law enforcement”? Monasteries in Western Tigray with religious texts hundreds of years old were attacked with their treasures destroyed and clergy assassinated. The ancient Ethiopian Orthodox Church which traces its roots to the early Jewish religion of Menelik I and then the Christian kingdom of Ezana in Axum was desecrated with the murder of at least 80 unarmed worshipping civilians. What does that have to do with “law enforcement”?.

Aksum’s Our Lady Mary of Zion Church where Eritrean soldiers killed civilians

It is well documented that Eritreans, ENDF, and Somali mercenaries destroyed factories and businesses including those of foreign investors who generated income for the Ethiopian government and provided employment for civilians. Many pieces of equipment of not only these but also the national Ethio-telecom company were taken by Eritreans as war bounty to Eritrea. How does this destruction of Ethiopian federal property qualify as “law enforcement”?

The invading forces were instructed to destroy seeds and prevent farmers from planting crops. Many livestock were killed to be consumed by no one or taken to Eritrea in trucks. Both aid and commercial food supplies where blocked from entry to Tigray. Gradually both the Federal Government and the government of Amhara began to change their tune to explain this by saying that the population of Tigray was too supportive of the TDF and that NGOs were smuggling weapons with the aid. They accused organizations with much greater long standing reputations of wrong doing with no evidence instead trying to cover their own genocidal intent.

The government of Ethiopia as late as 2019 was a signatory to the Genocide Convention of the United Nations which states verbatim any of the following acts committed with intent to destroy, in whole or in part, a national, ethnical, racial or religious group, as such:
Killing members of the group;
Causing serious bodily or mental harm to members of the group;
Deliberately inflicting on the group conditions of life calculated to bring about its physical destruction in whole or in part;
Imposing measures intended to prevent births within the group;
Forcibly transferring children of the group to another group.

The treaty recognizes the following two elements of the crime

A mental element: the “intent to destroy, in whole or in part, a national, ethnical, racial or religious group, as such”; and

A physical element, which includes the following five acts, enumerated exhaustively:

Killing members of the group
Causing serious bodily or mental harm to members of the group
Deliberately inflicting on the group conditions of life calculated to bring about its physical destruction in whole or in part
Imposing measures intended to prevent births within the group
Forcibly transferring children of the group to another group

Mekelle Unarmed Civilians Brave Defense of Their Beloved Hospital-Ayder Comprehensive Specialized Hospital

drone view of Ayder Comprehensive Specialized Hospital
Shows Ayder Hospital and the streets lining it where a brave protest took place. Pictures I had of the events described were erased by Eritrean patrols that would search me everyday I went to the hospital I will never forget the bravery of the people in Mekelle who unarmed defended their hospital. This picture shows the streets around Ayder Hospital where it all happened.

This is the story I witnessed of the brave unarmed civilians peacefully protesting and blocking invading forces from ransacking Ayder Comprehensive Specialized Hospital in Mekelle, Ethiopia in November of 2020. I had been performing neurosurgery, teaching fellows, and medical students at Mekelle University  in the Tigray region of Ethiopia since 2015 in a federal university and hospital.  As such I was present in Mekelle from the onset of the war between the Tigray Defense Force and the Ethiopian/Eritrean forces from the onset until my evacuation near the end of December 2020 at the behest of international influence and my family which was three days of driving through multiple checkpoints and unstable areas until we finally arrived in Addis Ababa.

Following the retaking of Mekelle by the Tigray Defense on June 28, 2021 there has been a mixture of sadness and joy. For sometime I have wanted to tell the story of what I think was the most heroic thing I have ever seen in my life which was the unarmed defense of Ayder Comprehensive Specialized Hospital in Mekelle. Prior to this time I felt telling it would result in reprisal to the citizens of Mekelle. Now that Mekelle is free it is important to tell it.

For almost 24 hours on November 25, 2020 the city of Mekelle was attacked constantly by artillery, rocket attack, and airstrikes even though the Tigray Defense Forces had left the city to only civilians.  In my own immediate neighborhood just a few blocks from the Mekelle University hospital, Ayder Comprehensive Specialized Hospital many homes and buildings were destroyed and many killed. A market and home for elders was directly hit killing and wounding many.

About 200 yards from my house, a home that housed a large extended family suffered a direct hit that sent shrapnel breaking my windows at about 6:30 in the morning. I ran over there to find a young woman in the street with a severe bleeding wound in upper leg but that was just the beginning of the horror. The walls of the house had been destroyed on two sides and the rest looked like a Swiss cheese with many perforations. On the ground was a motionless young woman who had only a red spot on the ground where her chest was supposed to be. Her lifeless arms were extended with each one holding toddlers. The children where crying. When I pulled back their hair I found that hundreds of small munitions fragments had penetrated the scalp of both children although the eyes seemed okay. There was nothing we could do for the mother nor her mother who lay beside her dead as well from penetrating shrapnel. Remaining family members rushed the sister with the injured leg and the children to Ayder Comprehensive Specialized Hospital. 

At the hospital emergency room there was wave after wave of ambulances and private vehicles bringing those hit by the attack who were all civilians. Some could be helped but many were beyond hope. We were able to save the children and their aunt from the attack near my house. Although we would sometimes previously do mass casualty from bus accidents in the past this was a much greater magnitude as we saw more then 120 patients in the first few hours. 

Before the invasion of the city, we had been receiving civilian causalities,  Tigray Defense Force causalities, and also Federal/Eritrean causalities. We treated them all the same. The local people even brought food and blankets for the all the groups. However after the invasion the tenor of the invading force changed. Many patients were just suddenly whisked away to parts unknown and we were not allowed to inquire.

The next day on November 26, 2020 at which time Federal Ethiopian armed forces and Eritrean forces invaded unopposed the city of Mekelle.  For the next few days in Mekelle there were Ethiopian and Eritrean forces looting, shooting, robbing, and harassing civilians all around the Ayder area where I lived and the hospital was located. The hospital was occupied by Ethiopian army regulars, then Special Forces from Oromia, and so-called Federal Police. Then suddenly for about half a day they disappeared.

Rumors where flying in the city that Eritreans where ransacking public utilities, schools, etc. The hospital had always been a source of pride and necessity for not only Mekelle but all of Tigray. The local population of civilians began to put tires, logs, and stones to block trucks or other vehicles in the streets surrounding around Ayder Comprehensive Specialized Hospital, the main teaching and tertiary hospital for Tigray, fearing that the hospital which was highly valued by the city would be destroyed or looted. Special Red caped soldiers showed up and began harassing the locals more and more. 

The locals did not back off. They gathered by the thousands and began to surround the hospital 24 hours a day. Many times semitrucks and smaller trucks driven by Eritreans which were empty tried to make it to the hospital to loot it but where physically blocked by protestors standing in their way.  At one point a group of young men were shouting about ten feet in front me to the soldiers. Suddenly the soldiers fired at them killed one and injuring two others. At that time there were tires burning all around the hospital with thousands of protesters. The soldiers were scared and I feared the worst was going to happen. It was tense until morning. Finally the lined up trucks driven by plain clothed Eritreans were told to leave by the invading forces. The two that survived to be treated were hauled off from the hospital by the invading forces and have not been seen again as far as I know.

Pictures I had of the event were erased by Eritrean patrols that would search me everyday I went to the hospital but I will never forget the bravery of the people in Mekelle who unarmed defended their hospital. 

The Growing Infant Meningitis Crisis in Ethiopia

 

MRI of infant with meningits
Infant with meningitis seen on MRI to have hydrocephalus and meningeal enhancement

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.

Systemic deficiencies
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.

Head Injury Guideline for Northern Ethiopia from Mekelle University Neurosurgery Department

 

 

Depiction of ambulance coming to Ayder Comprehensive Specialized Hospital
Ambulance coming to hospital

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.

Adult Glasgow Coma Scale
Adult Glasgow Coma Scale

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)

Adult Glasgow Coma Scale
Pediatric Glasgow Coma Scale

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
unavailable
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
–limb movements
–respiratory rate and oxygen saturation
–heart rate
–blood pressure
–temperature
–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
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.

Indications:
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

Infection Prophylaxis
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.

DVT Prophylaxis
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.

Hyperventilation
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.

Steroids
There is no sound scientific evidence supporting the use of steroids for head injury.

Barbiturates
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.

Post-Traumatic Meningitis
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.

Epidural hematoma
–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.

Finely Controlled Hypotension during Brain Surgery in Ethiopia

Brain surgery being done with controlled hypotension at Ayder Comprehensive Specialized Hospital

At Ayder Comprehensive Specialized Hospital, the university medical center for Mekelle University in Ethiopia, our experience with finely controlled hypotension during brain surgery for both adults and children has reduced the need for blood transfusion by half. 

In many underdeveloped African countries the surgical treatment of brain tumors is often very late in the course of the disease due to delay in the patient seeking treatment, having a diagnostic study to find the tumor, and being scheduled for surgery as many university centers have long waiting lists. Such is the situation we are in Ethiopia. These large brain tumors, often 10 centimeters or more in diameter, can require massive transfusion during the surgery to remove or reduce them. 

Large meningioma which has risk for high blood loss during surgery

The Department of Neurosurgery in the School of Medicine at Mekelle University in a close partnership with our Department of Anesthesia has been working on creating sustainable safe controlled hypotension techniques to reduce our blood loss during brain tumor surgery in adults and children at Ayder Comprehensive Specialized Hospital.  Thanks to the donation of a high quality intravenous perfuser by a diaspora American anesthesiologist and the cooperation of the university to gain stocks of Isoflurane  inhalation agent and Propofol intravenous agent as well as in house training together we have significantly reduced blood loss leading to much less transfusion during brain surgery. End tidal CO2 is kept at 4.5 to 5% and mean arterial blood pressure maintained at 65-70 mm/Hg.

brain surgery under controlled hypotension