Honduras Clinic Journal Visit 2

We just finished, and a 25-year-old woman stumbled in. On the bus to her appointment, she had a tonic-clonic seizure. She was sleepy, and spacy, but remarkably intact cognitively.  She has had 10 seizures per month. Despite the epilepsy, she functions fairly well, taking care of her small farm, as well as her 3 kids. She lives up in the mountains, and it takes all day to get to our clinic.  I put her on one of the seizure meds that we brought in from the U.S: Keppra.  It is safer, and probably more effective than the meds that most Honduran patients take (Dilantin and phenobarbital: these are our old meds, still used here occasionally). Very sad, she is a wonderful young lady, bright,  but is losing too many brain cells with this amount of seizures. (NOTE: I subsequently Skyped with her; she was much improved on the Keppra, down to zero or 1 seizure per month: the issue now is, down from 10 per month to 1, should we try for zero: in general, yes, we want to have no major seizures; I did push up the dose of the Keppra.)

A woman brought in her 39-year-old sister, who was okay until a year ago.  For one year she has had:  staring off into space, a flat affect, tremulousness, dementia, very little verbal output, little appetite, and she sleeps a lot.  Her exam revealed hyperreflexia (probably due to white matter disease in her brain.)  The differential is long, and includes; a buildup of copper in her liver (Wilson’s disease),  other miscellaneous metabolic errors, and miscellaneous causes for younger age dementia.  She needs a huge work-up.  I did labs, which are difficult to obtain (primarily due to the cost.)  I now have a few neurology connections in the city, including Dr. Heike Hesse, who is a dementia sub-specialist.  However, it is a long shot that she will actually make it there.  One obstacle is that the patient cannot just call and make an appt.  They have to make an all day trip to Teguz, via 1 or more buses, in order to make a future appointment.

While lying in the middle of the nite I had this epiphany: Tele-Neurology, thru Skype. The reason I don’t do it in the USA is malpractice, which is not a factor in Honduras.  So, we are putting in a modem and cable into the clinica.  (Note: subsequently, we have been Skyping. We have an interpreter sitting with me, and the bilingual doctor sitting with the patient. It has worked pretty well (BUT: we do lose something by not being in person, and it’s not as much fun).)

I saw a 8-year-old girl, with 4 years of daily headache and migraines. Her mom denies any family history of headache; the girl is developmentally delayed, with ADHD. She drove us goofy during the visit; she has severe hyperactivity, and is fairly impulsive. Then  mom was the next patient and she also has migraines (even though she denied a family history of headache.)  I had a little squishy toy “brain” in my bag (from some drug company) and it has been a life-saver. The kids play with it, and this little girl with ADHD loved it.

Today I had a 55-year-old woman with intractable chronic migraine sent from her neurologist in Tegucicalpa. It is an interesting trip from Tegucicalpa to our semi-rural clinic. There are feral dogs, horses, and cows along the way. It is one lane, and not all that safe. There is no AAA if you break down.  But I digress.  So, I spoke to her with my crummy Spanish for awhile, asked some questions, only to discover that her son, who was with her is a doctor, and he speaks English!   We went over all the possibilities, but unfortunately, for refractory headache, there is no Botox available.

Medicine is fairly simple here. There is no HIPAA (HIPAA seems about 20% good, 80% not so good), no insurance, and no paperwork. It is simple. Plus, malpractice is rare (in the city only, on rare occasions.)

I saw a 66-year-old woman with rapidly progressive dementia. She was fine until 45 days ago, but now is mute, with very poor balance, and an abnormal neuro exam in other ways.   This rapid progression is not encountered very often.  I am checking for something simple that could be treated (thyroid problems,  etc.), but am not very optimistic.   I think I know what it is NOT: Alzheimers, LBD (lewy body disease), vascular, alcohol (Wernicke-Korsakoff), CNS vasculitis, adult onset bipolar or psychiatric. What it IS, we may not find out.

This could be infectious (although unlikely), and she needs an LP (spinal tap.), along with an MRI.   I gave her thiamine and a multivitamin, which can’t hurt. I gave these because if it is alcoholic related (Wernickes), thiamine can be a lifesaver.  Empirically, I also gave her Prednisona (cortisone), which could help if it is inflammatory.  I will try and get her into the hospital in Tegucicalpa, to see Heike Hesse, M.D., dementia specialist.

I saw a woman with severe trigeminal neuralgia,  or at least that was her previous diagnosis. She was intent on getting surgery for the condition. I tried (maybe successfully) to talk her out of surgery. My reasoning was: 1.surgery can make it worse, although it could help, and 2. she  has a rather unusual headache type (chronic paroxysmal hemicrania(CPH): this is different than trigeminal neuralgia), which surgery does not help.  She does want the surgery, but we went over all of the pros and cons. What she needs is indomethacin, which chronic paroxysmal hemicrania(CPH) responds very well to. CPH is a condition where people have one-sided daily pain, usually frontal and temporal, with some eye tearing, eye redness, nasal stuffiness.  The pain is often intense and ruins any quality of life. It seems to only do well with indomethacin, an anti-inflammatory.  However, I do not believe that we can find indomethacin in Honduras. If available in a neighboring country (such as Guatemala), she can find it there.  Maybe. 

A group from Canada comes in to our rural area, and they build wells in towns that have no water at all.  They also do other construction projects. They are true heroes (and they pay for everything: all construction materials and costs.)

The honeymoon sometimes is over (it happens in my office also). When I give a med such as  sumatriptan, which helps 65% of people, patients are excited about the possibility of finding something that actually stops the migraine. When it does not work, or gives side effects, inevitably it is disappointing.  Then we scramble around for some alternative.  In the U.S., we have a number of other possibilities, but in Honduras our choices are very limited.  After age 50, we don’t want to kill people’s kidneys and stomachs with NSAIDs, so we greatly limit those.  We end up prescribing a pain medicine, such as tramadol.

So when I ask ‘how much coffee do you drink”, we obtain some funny responses.  If the person starts giggling, the amount often is more than 6 cups per day. Honduran coffee is rich and tasty.  They do not have Starbucks. Decaff is usually nowhere to be found (when I mention decaff, they look at me like I am from another planet.)

Adjusting anti-seizure medication doses in a 6-month-old is challenging. I need a solid medication guide.  For the previous trip, I lugged actual medical books.  This time I have my Kindle with the medical books on it, which are a bit more difficult to use than are regular books.  I need to hurry and finish our Honduras neurology formulary (no formulary or resource guide to the meds exists here, unfortunately.)  It will help all of the Honduran docs that we can give it to.

The child with neurofibromatosis came back. I had seen him some time before.  There are some experimental meds, but unfortunately it is a downhill and progressive illness.  His mom spoke of bringing her child to Houston for treatment.  I assumed she is on the computer (most are not), and knows about the the long-term outlook, but I am not sure. I was not about to have that discussion. Maybe next time we will have that discussion very gently.)

I am still frustrated about no medication list. I have to call local farmacias to ask what may be available, for various conditions.   Many of the meds that I thought would be available are technically in Honduras, but indeed are nowhere to be found.

A woman  came in from a nearby town, Danli. Danli has several hundred thousand residents, with no neurologists (that I know of.)  She had on a University of Kentucky Wildcat basketball shirt. Blood tests in Honduras are expensive.  We are paying for some of the tests.  I am choosing meds that do not require blood tests, as people cannot afford them. The minimum wage is about $400 per month. So, for scans, if an MRI is $250, or a CAT scan $150, they just cannot obtain the test.  Some people will be able to do the test, for very low cost, at the Tegucicalpa Public Hospital.  It is possible for a small number of people to go across to Nicaragua, and obtain a much less expensive test.

Surprisingly, they use very little “natural” remedies, much less than when compared with the US.  They don’t usually take much in the way of vitamins. I try to place the patients on anticonvulsants on vitamin B, or a multivitamin. I also emphasize teeth brushing to many of the epilepsy patients. This is particularly important for those on the older epilepsy drug, Dilantin.  I often try to discontinue the Dilantin, and place patients on Keppra, which I bring in with me. Keppra does not injure the gums, does not require blood tests, and is more consistent and effective.

The patients do not use many opioids, save for a mild one, tramadol. The chronic pain patients do not ask for pain meds.

I see little addiction. I am told that most people cannot afford illegal drugs. The government does not look kindly upon marijuana, which certainly is not legal.  I am not sure of the rate of alcoholism, but it seems less than in the States.

Anxiety and depression are not quite as prevalent as back home. Maybe this is due to a simpler, non-electronic life. There seems to be less isolation in Honduras, as family members often live together. They usually watch out for each other. Most with migraines just soldier on with nausea and a severe headache.  The person usually keeps working, plowing thru with no effective meds. The sumatriptan (an abortive, not a preventive) that we bring in often helps. It is mighty tough to work in 95 degree heat with a severe migraine. Particularly when it is bright and sunny.  However, for most, if they do not work, they don’t get paid. Many of the women are housewives, and they have no choice but to keep functioning. We do have some older migraine meds available, such as variations on ergotamines. However, the triptans are a significant upgrade.

I see a number of teens who have suffered various degrees of abuse, with resultant PTSD.  The ACE questionnaire would help, which are 10 questions that help to categorize the degree of trauma. 

Traumatic brain injuries (TBI) are common. The playgrounds are like our U.S. ones in the 60’s (not so safe.) The result of some of these may be severe headaches, or epilepsy.

I saw a 52-year-old man with epilepsy on phenobarbital, an old medicine. He had a seizure recently because  “I forgot to take my medicine”.  I told him that phenobarbital (with a ½ life of 96 hours) lasts 3 weeks in the body, he said “yea, I forgot to take it for a month!!” This older drug, phenobarbital, may cause sedation, and is not an ideal anticonvulsant. However, it is cheap, and if one forgets it for days to several weeks, it usually will continue to be effective.

I saw a 9-year-old young man with new onset daily headache, with migraine features. He does have a family history of headache. I would like to obtain a brain scan, but this may not get done. We will see.

People deal quite a bit with early deaths. A number of moms say “I have 6 kids, but one died at age 18.” Violence, disease, and lack of medical care take a fierce toll.

I have encountered some cases of autism and Fragile X syndrome. I adjusted the psych meds. Support services are usually not available, or affordable.

I saw a 54-year-old farmer with severe facial itching.  I told him that I also had an itching problem.  I wanted to tell him about the “itching chat boards” on the internet, but he has no internet access. I prescribed the same meds that did not work for me, but occasionally they are mildly effective.  He seemed glad to hear that I also had itching.

Setting up SKYPE and teleneurology has allowed me to keep in touch remotely. WhatsApp is remarkably useful, better than simple messaging.  Email is our lifeblood of communication. Even 18 years ago, none of this would have been possible in Honduras. 

We see so many tough life stories, and the incredible resilience of the most of the Honduran people is amazing. Also, people are very grateful for everything that we are doing.

Hasta Luego,   Larry Robbins,M.D.

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