Dr Robbins Fourth Visit to Honduras

Note: the patients here have been “de-identified”, with details altered somewhat, to protect identities. This journal is based upon a visit to our clinic in late 2018.

 

I saw a 19 y.o. young man with a life-long history of epilepsy(grand mal, or tonic-clonic, seizures). He has rather frequent seizures, and is not on the right medicine. Of course, his mom brings him in; mom’s here are, in general, very caring and protective(as are most moms, of course). Moms are moms, and parents are parents, whether in a wealthy U.S. suburb, or in rural Honduras. I started this young man on Keppra, as it is a safe and effective medicine, but rather expensive. This young man is remarkable, in that he taught himself to read and write. I thought, for the first part of the visit, that he was non-verbal and significantly delayed. He is behind, but is fairly bright and high functioning. The main problem is that all of those major seizures take a toll on his neurons.

 

NOTE: several months after this visit we indeed were running out of Keppra. I thought that I had brought enough for 3 or 4 months, but apparently not. So, until I was able to visit there once more, with more Keppra, we had to buy more from local Honduran sources. Some drugs are much cheaper in Honduras, but Keppra is significantly less in the United States. Because it is difficult to keep it in stock, I will transition to using more topiramate(Topamax), as it is easier to supply this med. Also, for select patients we will use the older drug phenobarbital, as this is a fairly reliable seizure med, and is cheap. I can’t bring in phenobarbital(it is a controlled substance), but we can obtain it in Honduras. Phenobarbital has the advantage of being very long-lasting(half-life of 96 hours or so), so if patients miss a dose, or run out, they are protected for weeks. On the minus side, phenobarbital causes sedation, does not mix well with alcohol, and should(in theory) require occasional blood tests.

 

I saw a father and son, 48 and 22 years old, 2 peas in a pod. Both have headaches and insomnia, and both dad and son have done well on imipramine. Imipramine is an old antidepressant that we use for preventing headaches. As a sidelight, imipramine often helps sleeping as well. The problem is cost. Imipramine is relatively expensive here in Honduras, while I can bring in a similar medicine(amitriptyline) for next to nothing. So, we will transition over to the amitriptyline. Even if a drug is not quite as good, if patients can’t afford or obtain the better one, the inferior one is usually acceptable.

 

I saw a 43 y.o. with sleep paralysis. This manifests by the person’s inability to move in the minutes prior to going to sleep. It does not last long. This happens to many people randomly, and some get it regularly. Although the body cannot move, the brain is working fine. It is a weird feeling. The unusual thing is, after the sleep paralysis, she has a migraine. This may be an unusual “prodrome”, or possibly an aura, to the migraine. Prodromes, prior to the onset of pain, often consist of feeling very tired, or depressed. Occasionally we see mild mania prior to a migraine as the prodrome. One patient’s husband told me he knows when his wife will have a migraine, as she starts to obsessively clean everything at home. The prodrome has to be distinguished from the aura of a migraine, which usually is brief(several minutes, up to 30 or so; occasionally it may be much longer).

With this woman, after the sleep paralysis, she has a migraine, and usually faints during the migraine. This we occasionally see, but not that often. I did give her sumatriptan to take after the sleep paralysis wears off. I bring in thousands of tabs of sumatriptan(Imitrex), which has been transformative for many rural Honduran patients. Prior to the sumatriptan, which works well in 65% of patients, they resorted to the older ergotamines. These older drugs are not particularly safe, and they have more side effects.

I went to the Public Hospital in the main city, Tegucicalpa, to teach. The hospital is like our county hospitals, but with more patients. Outside there are many vendors serving up food, and booths with all kinds of stuff. It is wall to wall people, teeming with life. There is security at the entrance, because they do have lots of guns in Honduras. However, the personal gun laws are strict; most guns are illegal, brought in from surrounding countries(Nicaragua, Guatemala). When the surrounding countries have a civil war, guns stream into Honduras.

We had to walk up 5 flights. This reminded me of my training at the old U. of Illinois charity hospital in Chicago, where the elevators would crawl so very slowly. We usually walked the 10 or 13 flights. I gave a talk, Deconstructing the Art of Medicine and Headache Medicine, in my curious mix of bad Spanish and decent English. They did have good technology; when I was demonstrating how to do an Occipital Nerve Block, they put up on the screen Youtube video demonstrating the nerve block. The neurology residents and attendings were very interested, and I will come back. During the talk, I was speaking about bipolar and personality disorders. A young woman psychiatrist, Laura, spoke up, in perfect English. Subsequently, we have hired her to work in our rural neurology clinic. She will be a big addition. Psychiatrists are few and far between.

 

I realized that I need to bring in(from home) meds for Parkinsons and myasthenia gravis. These are available in Honduras, but 97% of people cannot afford them. (note: for the next visit, I have purchased many thousands of tablets for these conditions. The medications need to last 3 or 4 months.)

 

I saw a 44 y.o. woman with epilepsy, doing well on topiramate BUT: she is losing too much weight on it(topiramate often decreases appetite). Of course, sometimes this is not a bad problem, but she was not overweight to begin with. I will have to switch meds: 1. To Ceumid(Keppra), which is mild and safe BUT: we have trouble keeping it in stock, or: 2. To phenobarbital, an older one, with it’s pluses and minuses.

 

3 times in the past 6 weeks we have had to order emergency supplies of Ceumid, a great seizure med; we just cannot keep it in stock. We do now have our own section of the “Farmacia”, with a locked cabinet. I have asked our new neurologist, Dr. Estrada, to use less Ceumid, and more of the others. In a few weeks, I am bringing in about 22,000 pills of various sorts(neurologic, psychiatric). This includes some Parkinsons meds, and Mestinon for myasthenia gravis. Dr. Estrada was very excited after his first visit to our clinic. He treated a young man with a craniopharyngioma(embryonic tumor, you are born with it…it is a very strange type of tumor, can have teeth and hair in it, in the middle of the brain). He emailed me the MRI, showing a sizable tumor; hopefully the young man will get surgery.

 

I saw, in follow-up, a 14 year old young woman with seizures and developmental delay(moderate to severe). I had started topiramate 3 months earlier; this had reduced the seizures from 30 per month, down to 2. I would like to get to no seizures.

 

We did download a meditation sheet, in Spanish. This helps. Here in the U.S. I can point people to certain Apps, but in Honduras most do not have access.

 

I saw a young man with an acute traumatic brain injury, and I wanted him to get a scan in the main city. This is not easy to do; there is no ambulance available. Luckily he came in with someone who actually could drive him to Tegucicalpa. Whether he gets the scan or not is iffy. I hope so, as he has a possible subdural hematoma(bleed).

 

I saw a 17y.o. young woman, with difficult cyclical(6 weeks or so) migraines, and POTS. POTS is a fairly common syndrome, mostly occurring in young people. It is basically a faster heart beat when one stands up; sometimes there is also a drop in blood pressure. POTS often gets better over time, and is treated with beta blockers(high blood pressure meds that decrease the heart rate). POTS patients often have migraines as well.

 

I treated a 42 y.o. with seizures and headaches with topiramate. She came back in 3 months later; the epilepsy is fine, but the headaches are not. As much as I want to minimize meds, I felt the need to add a headache preventive to her regimen. As needed for a migraine, the sumatriptan I gave her works well. Almost none of our patients can afford sumatriptan, but we have plenty in stock.

 

I saw 3 generations, one after another, all with the same type of headache. The grandma, daughter, and 10 y.o. grandson, all had one sided anterior(frontal) severe headaches, with nausea and sensitivity to bright lights and loud sounds. So, what works for one in a family may work for the others; there is the “placebo by proxy” effect: if mom has a great response to sumatriptan, it is more likely that her daughter or son will also have a great response, one factor being the placebo effect. Another factor, which is more important, is genetic. The other advantage of giving 3 generations the same sort of medication is that, if one person runs out of, for example, sumatriptan, the others have some around.

 

I saw a one year old. He had been dropped by the mom when he was one month old, landing partially on his head. They brought him into the Public Hospital in Tegucicalpa, where he had a scan of his brain(infants often bleed in the brain due to trauma). His scan was fine, as was he. However, the parents were “Nervous Nellies”, and the mom felt guilty. I examined the child, and the neurologic exam was fine. He was progressing normally regarding neurological markers. I tried my best to reassure the mom. She wanted to bring him back in 3 months, so I will see the little baby again, sit him up, look behind his eyes, and pronounce him “fit as a fiddle”.

 

I saw a young man with bipolar illness, with mania. I spoke about the different classes of mood stabilizers(antipsychotics, lithium, and the seizure drugs). I will follow him; luckily our terrific young psychiatrist, Laura, is working and will follow up with him. We are bringing in all of these psychiatric medications.

 

Adios para ahora …………..bye for now LR

 

 

 

 

 

 

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