A Free Neurology, Headache, and Psychiatry Clinic in Honduras, Part 2

Larry Robbins, M.D. Associate Professor of Neurology, Chicago Medical School. Professor of Research, DMU College of Osteopathic Medicine.  Private practice in Riverwoods, Ill.  lrobb98@icloud.com

Genesis Mejias, M.D.

The Patients and People:

Part 1 consisted of the combination of Beginning Goals, Staff, Medications, Charts, Pain and Headache Patients, Teaching and Accommodations.  Part 1 can be found in the SPS Summer Newsletter.

The following is a sampling of some of the patients I have seen. The names and key facts are changed to protect identities.

95% of patients can’t afford to see a neurologist or a psychiatrist, or to pay for the meds. They are overwhelmingly hardworking, nice people just trying to get by in life. We see all ages, newborns to 100 years old. To arrive at the clinic, they often travel many hours via two or three buses.

Rosa is a 28-year-old woman who stumbled off the bus on her first visit, after having a focal impaired seizure. She had traveled three hours from the mountains. We were closing for the day, and she was a bit confused. Rosa usually had 25 to 40 focal impaired seizures per month, and 4 to 7 tonic clonic seizures as well. She was on phenobarbital and phenytoin for many years. No tests. I switched her to levetiracetam eventually pushing the dose to 1000mg twice daily. I bring in a lot of levetiracetam, due to its efficacy and safety on the levitiracetam, Rosa has only two focal impaired seizures per month, and no tonic-clonic ones. She is a bit tired on the levetiracetam, and I have considered switching to lamotrigine. Rosa lives in the mountains and grows coffee which she brings to us. She wanted to bring me a live turkey. The patients are incredibly thankful that we are there for them. An important aspect of our clinic is the relationship. It’s so important to many of our patients.

Juan is a 66-year-old agricultural worker with Parkinson’s for four years undiagnosed. He has had five falls in the past three months.  He may have had longstanding exposure to pesticides. Juan had several severe traumatic brain injuries (TBIs) as a young man, and he played soccer from age 3 to 35. TBIs seem to be more prevalent than in the U.S. The repetitive subconcussive blows and also concussions from decades of soccer don’t help. There is a fair amount of physical abuse in Honduras, although hard to tell if it’s more prevalent than in other countries. We do see quite a bit of epilepsy, chronic migraine, and neurodegenerative illnesses. Without epidemiologic studies I can’t definitively say that these are more prevalent than in other countries. Juan has not been able to work for several years. I stressed the importance of exercise. There are no health clubs available to 95% of the population. As with almost all Honduran people, Juan does walk a lot (about five miles per day).   I placed him on carbidopa-levodopa (25-100), eventually titrating to TID. He does have three reasonably good hours after taking the med.  Carbidopa-levodopa is too expensive for most Hondurans. I bring in about 4,000 tabs every three months or so, but those go quickly. When he runs out, he just goes without the levodopa.

I saw two children, both nonfunctional with multiple seizures – one with probable West syndrome, the other with Lennox-Gastaut. Both had severe birth injuries, which we commonly encounter.  Not having prenatal care and vitamins is one issue, the other being the difficulty in obtaining a C-section.  The moms are incredibly devoted.  One mom did NOT want to go to a cheaper medicine, she said “give my son the best”…..they are spending one half of the family income on the child’s meds.

The patients often are accompanied by family members. Many parents, usually the mom, are heroic in how they sacrifice for their children.  The society is less isolated than what we see here in the U.S.  People cannot afford to live alone.

We had two patients in the ER at the same time in T-C status epilepticus. It is always a scramble to find a “pam” for status, usually lorazepam or diazepam. Most of the status epi we see is due to running out of their meds. One of these patients is an 8-year-old boy with a left temporal lesion. We are trying to convince his mom to allow him to undergo epilepsy surgery. The Honduras epilepsy surgery department is relatively new.

A 21-year-old woman with new onset Bell’s Palsy (left facial palsy), could not close her left eye, with the unusual symptom of right upper lip numbness (? brainstem involvement).  I had her apply Vaseline to the eye area, and I gave her Prednisone.

A 16-year-old young man with probable neurofibromatosis type 1. He has mild developmental delay, eight skin neurofibromas, four café au lait spots, mild axillary, but no groin freckling, and tonic-clonic seizures. No Lisch nodules were apparent. His epilepsy is controlled on phenobarbital, so we will leave that alone. We will do an EEG, but obtaining an MRI may be a long shot. His vision is ok, but I am wondering about the presence of an optic pathway glioma.

I saw two sisters in their 30s, both with trigeminal neuralgia.  Only 1 or 2% of cases are felt to be “hereditary”: a number of possible genes have been identified, but whether it’s truly “hereditary” is murky.  I put both on carbamazepine. We do have amitriptyline, duloxetine, lamotrigine and gabapentin available. Cost of the meds will somewhat determine what I prescribe.

I have my neurology books on my I-Phone.  It’s easier to have “regular” books. Internet access is ok but spotty, and searching an index on the I-Phone is cumbersome.  I have a wonderful interpreter. The chart notes are mostly in Spanish, and I have difficulty deciphering them. The other doctors can’t easily read my scribble. This is a problem.

I saw one woman with a head injury from domestic violence, and another woman who had been shot in the face during a robbery. She recovered from the gunshot to some degree but is very depressed……not a lot of support from her family……I prescribed fluoxetine. Psychotherapy is not available. I wanted to start a program that has been successful in Africa, where lay people are trained to listen and function as a type of therapist. I have run into barriers in Honduras with this project.

I encountered a sad situation: a 43-year-old obese man who 5 years earlier had taken a dive into the river.  He struck his head and is paraplegic (C6-C7 injury). He only recently received a wheelchair so that he can finally venture outside.  He is usually stuck in the house 24/7. His wonderful wife brought him into our clinic.  They have two teenage children. I spoke to him quite a bit about weight loss and am trying to arrange physical therapy, but that may not happen.  He is a computer specialist and can at least work from home.

A 53-year-old woman came in with three months of daily headache, nausea, and right sided weakness. On follow-up six weeks later, she did bring in her MRI. The scan revealed a left frontal glioma. She has six children. I placed her on steroids and lamotrigine. Hospice is not available.

An 11-year-old behaviorally disturbed boy, fights a lot and has no friends who is on fluoxetine and phenytoin. He has no empathy, and has been suicidal for two years. He exhibits ultra rapid cycling, aggressive, threatens family with a knife. No early trauma. Differential diagnosis is bipolar vs. personality disorder (i.e., antisocial/borderline) vs. a combination of these. I discontinued the fluoxetine, which has probably worsened his symptoms.  I prescribed lamotrigine. They cannot afford valproate which is expensive in Honduras, and if on valproate he would need blood tests. The lamotrigine does not usually require blood tests, and we can supply the medicine. As far as psychotherapy is concerned, it’s difficult to find, and primarily for the wealthy. The psychiatrists focus primarily on the medications.

I saw a one-year-old for neurologic evaluation. He had been accidentally dropped by the mom when he was one month old, landing on his head. They brought him into the Public Hospital in Tegucigalpa, and he had a normal scan.  However, the parents are highly anxious, and the mom feels guilty. The neurologic exam was fine. The mom has brought him in every 6 months, just for reassurance. This may be my easiest consult.

I saw a 12-year-old young man in sixth grade who can’t read. He has attention deficit disorder and a learning disability. He is a nice kid in a sad situation.  He has had some tutoring but not very much since special education services are hard to come by.  I prescribed methylphenidate, but it is becoming very difficult to obtain. The teachers do heroic work, often with too many pupils. There are many children who are unable to read or keep up in school. They don’t have special services available to them.

One mother brought in a 14-year-old young man who had fallen and struck his head. He had LOC, with a full day of amnesia. He has post-traumatic tonic clonic epilepsy and headaches. We encounter a lot of TBI in Honduras. Subsequently we see quite a bit of post-traumatic seizures, headaches, cognitive, and emotional problems.

To be continued…..