The Road Back to Dnipro: “Third Time’s A Charm!” Rocco Armonda, Alex Valadka, Bohdan Sirko, Andrii Sirko
Bloodied but Unbowed
The blast was enormous. Cold October air rushed through the shattered window into the operating room, which had momentarily gone dark. Dust and broken glass coated the floor, the walls, and the toppled equipment carts in the previously immaculate operating room. The attending neurosurgeon was 26-year-old Dr. Bohdan Sirko. He initially thought he was dead. Amidst the dust and haze, the persistent ringing in his right ear and the many medical alarms told him that he was still very much alive.
He was in the middle of an emergency craniotomy for a traumatic acute subdural hematoma in a combatant. After a quick assessment to make sure no one was seriously injured, he proceeded to finish the operation as rapidly as he could despite the wide-open window, shattered glass everywhere, and the persistent haze that filled the air. The 2000-kg glide bomb had landed 500 meters away, in the middle of a road near a side entrance to Mechnikov Hospital. Multiple hospital windows, ceiling tiles, and hallways were destroyed by the enormous blast wave. Bohdan quickly FaceTimed his father, Professor Andrii Sirko, Director of Cranial Neurotrauma and Neuro-oncology at Mechnikov. Bohdan told his father that he was alive and well and the operation had been completed. He would later text me some smiling pictures from the OR, attributing his survival to a US Army OR surgical scrub cap that I had previously given him and that he was wearing at the time.
Four months later, I assisted Bohdan in that very same OR, which was completely renovated and repaired. I wore my Ukrainian headcover while he wore his US Army scrub cap, which had become a valued talisman. During our joint operation on a Sunday evening, his third of the day, he performed a remarkable bifrontal decompression, frontal sinus exenteration, wound debridement, and dural repair with a vascularized pericranial flap. Neurosurgeons in the US who were 10 years his senior would be challenged to exceed his performance.
No Rest for the Weary
This was but one of many examples that we have seen of fortitude, equipoise and sangfroid in the face of unrelenting Russian terrorist attacks against hospitals, apartments, schools, libraries, theaters and coffee shops. Mechnikov Hospital continues to treat combat casualties, civilian emergencies, and patients with elective neurosurgical problems with a commitment unlike anything seen in the US. There is no such thing as being “full,” on “divert,” or “we can’t take another admission.” Despite sometimes having over 1670 patients in their 1200-bed hospital, they find a way, not an excuse. Nobody remains for hours in the emergency department, which is quickly cleared for incoming emergencies.
The burden is borne mostly on the shoulders of the nurses and doctors who continue their work despite the daily threat of Russian aerial attacks. Hospital rooms are adapted to handle the crush of incoming patients, including creating an ICU space in adjoining hallways. Unfortunately, the patient-to-nurse ratio in the ICU remains 5 to 1 in the best of circumstances, and occasionally at night 10 to 1. The hospital has currently treated over 40,000 combat casualties since the full-
scale Russian invasion began in February 2022. This volume exceeds by more than tenfold what we had seen in Iraq and Afghanistan. Drones, missiles, and artillery account for the majority of injuries. The on-scene treatment and evacuation of these casualties is made more hazardous by “double tap” attacks by the Russians, in which a second attack occurs a few minutes after the first, with the goal of killing first responders and medical evacuation teams.
Finding a Way, Not an Excuse
These casualty numbers are difficult to fathom. On our third trip, done consecutively in Feb 2025 and March-April 2025, it became obvious that the tempo of operations had not slowed down. The complexity of the cases remained high, with many cases of penetrating brain injury complicated by skull base and neurovascular involvement. Cumulatively, we assisted in over 25 operations, including complex neuroendovascular procedures and mechanical thrombectomies. The case load included combined penetrating brain and head injuries as well as complex skull base tumors. Outpatient consultations (clinic visits) were performed on almost 100 patients. Our visits included night shifts in the Neuro ICU and emergency department as well as online participation in a military medicine conference in the United States.
The number of admissions for war-related trauma continued to exceed 1000/month. A constant flow of patients from the frontlines to Mechnikov and then to hospitals in Kyiv, Lviv and the west continued on a daily basis. This was in addition to the patients with brain tumors, strokes, aneurysms, and AVMs that increased in number as the population of Dnipro grew by over 25% because of relocation of internally displaced Ukrainians from the east and south.
Despite this increase in volume, it was easy to see the improvements that the medical team had been making since my first visit almost two years earlier. The advances included a state-of-the- art biplane Philips neuroendovascular suite and outpatient center. The most advanced endovascu- lar techniques such as flow diversion, intra-aneurysmal neck devices, liquid embolics, and intracranial angioplasty/stent devices not yet available in the US were being used. In the single- plane angiography suite, over 200 mechanical thrombectomies have been performed so far, making Mechnikov Hospital one of the busiest stroke centers in all of Ukraine and in Europe.
The Young and The Brave
Under the tutelage of Andrii Sirko and Yuri Cherednychenko, young attendings--most between 28 and 32 years of age-- were now leading the way in developing new treatment paradigms for wartime neurotrauma. The many lessons learned from war injuries and civilian emergencies taught these young neurosurgeons to be independent in half the time of a US trainee.
Mechnikov’s large series of penetrating brain injury cases is making its way into the world’s literature. Soon the world will be able to see what we have witnessed over the past three years. These publications grow out of the tireless efforts of Professor Sirko.
We have created a monthly virtual neurocritical care conference with the Mechnikov team. However, one of these recent meetings had to pause for a few minutes because a Russian attack commenced just as the conference was beginning, and the team had to go to the basement shelter.
From My House to Your House
The tireless support of volunteers at Razom for Ukraine has grown and flourished as the war continues. In collaboration with Nova-Posta, Razom has delivered pallets of donated neurosurgical, neuro-endovascular and critical care equipment directly to Mechnikov for their vital mission. This collection occurs from hundreds of volunteers I have worked with across the country, crowd-sourcing essential selected items, packing them up in my garage, and then driving them via a rental truck to the Razom shipping facility in New Jersey. They are flown to Poland and then arrive at Mechnikov by rail and truck. These crucial deliveries continue despite unending Russian attacks on roadways and other infrastructure. Countless acts of bravery take place every day to deliver these life-saving supplies. It was always reassuring to see items being used at Mechnikov after they were delivered through this amazing network! This is a testament to the compassion and dedication of an amazing human chain of volunteers.
Women In Medicine
In Mechnikov and the entire Ukrainian medical community, women play a leading role in casu- alty care. This is evident at Mechnikov in neurosurgery, critical care, anesthesia, and nearly the entire nursing staff. After the full-scale Russian invasion, approximately 20% of the male physi- cians departed because of age, visa issues, or a desire to avoid the consequences of war. Few, if any, women have left, and if they do, it is only temporarily, for childbirth. We have witnessed the same dedicated OR nurses, in particular Karina and Olga, assisting in Professor Sirko’s complex neurosurgical procedures. Their skill is beyond the level of surgical assistants usually seen in the US. Their familiarity with the procedures allows them to minimize equipment needs to a few essential items. They anticipate needs before they become apparent. They remain for the entire case, without breaks. The speed of the operations is markedly enhanced by their diligence.
The same is true of the neuroanesthesia and critical care team. Natalia and Svitlana are experienced anesthesiologists who also cover the enormous Neuro ICU, which houses in excess of 60 patients. They are unfazed by emergencies and are efficient and beyond graceful in their management of complex multi-organ injuries. Their courage, compassion and expertise help Mechnikov function on a daily basis.
Each morning, Professor Sirko rounds with his nursing and ICU teams, ensuring that all overnight issues are addressed and that the team is updated on the current plan of action. Everyone treats each other with respect, admiration and support. Despite the extremely stressful conditions, they know that they can depend on each other almost like a second family.
Unconquerable
As we left during our separate third visits, one thing was certain: Ukraine will continue to fight and find a way to win peace with justice. Despite the trials and tribulations of a change in US administration, the Ukrainians remain steadfast in their mission. They have faced a sharp increase in numbers of aerial attacks since January. In the first 24 days of April, 848 Ukrainian civilians were killed or injured, a 46 % increase compared to the same period last year. An additional 40,000 Ukrainians have been driven from their homes, adding to the 10.7 million displaced people in the country. The Palm Sunday attack killing 35 people on a Sunday stroll in
Sumy and the 20 killed in Kryvyi Rih nine days before--including 9 children at a playground-- are just a few examples of the ongoing Russian war crimes directed at civilians.
Despite these losses, the Ukrainians did not waver or show any signs of weakness. Their resolve hardened. The tougher the conditions, the stronger and more robust was their response, from the battlefield to the operating room. In the neurosurgical arena they minimize waste, optimize their operations, and find new ways to improve outcomes. Techniques of tissue reconstruction, use of vascularized pericranium, microsurgical adjuncts for gentle debridement, neuroendovascular coiling of traumatic aneurysms, and stent grafting of cervical carotid and vertebral injuries are but a few of the many advances they have brought to the forefront. Injuries involving the poste- rior fossa, once thought irretrievable, were thoughtfully managed using these same principles. Instead of becoming dependent on technology, they use creativity, ingenuity and meticulous surgical technique to perform decompressions, debridements and complex reconstructions. Necessity is the mother of invention. Ukrainians have fully embraced this concept and are leading us toward the future of the delivery of neurosurgical care in a wartime environment.
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