Honduras Clinic Journal Visit 3

This trip was early August, 2018; a patient appeared again who, in March, had stumbled in as I was leaving the clinic. She has seizures, 20 per month or so; on the bus to the clinic in March, she had one, was post-ictal when she stumbled in. I switched her meds (to the Ceumid, which we bring in), and she went down to only 1 a month or so. She had told me she was going to bring me one of her mountain Honduras chickens as a present; so she showed up, having taken several buses to come on it, with a big bag; I said to Cato (interpreter) “I don’t know what to do with a chicken, and I would rather not take him on the plane back home’…she proudly gave me the bag and it was……cucumbers from her garden(phew)….

I saw 2 more kids, basically vegetative with seizures (severe birth injuries, which seems to be common); the moms are incredibly devoted; one did NOT want to go to a cheaper medicine, she said “give him the best”…..they are spending ½ the income on the child’s meds…

A 21-year-old woman with new onset Bells Palsy (left facial palsy), could not close her left eye, and the unusual symptom of right upper lip numbness (?brainstem involvement)….we had her put Vaseline in the eye area, tape it shut….the danger is the eye drying out, getting corneal ulcers and losing her vision…..put her on Prednisona…hope she is ok….

   11-year-old behaviorally disturbed boy, fights, no friends: on Prozac and Dilantin; no empathy;  suicidal for 2 years. Rapid cycling, aggressive, threatens family with a knife. No early trauma. Differential=bipolar vs. personality disorder (antisocial/borderline) vs. a combination of these. I switched Prozac, which has probably made him worse, to Keppra (Levitiracetam), which may act as a mood stabilizer. They cannot afford Depakote, and would need blood tests. The Keppra does not need blood tests, and we supply the medicine.

Young man, 12-year-old, 6th grade, cannot read; he has ADD and LD; nice kid, sad (has had some help, tutoring, but not very much); I prescribed Ritalin, will see if it helps; We can get Ritalin, but it is not easy.

14-year-old nice boy, had fallen and hit his head, now has post-traumatic epilepsy and headaches; there is a lot of TBI in Honduras, with post-traumatic seizures, headaches, cognitive problems. They don’t have the meds available to treat these injuries, or rehab facilities etc….

56-year-old with early dementia, probably was an alcoholic; I see relatively little drug abuse and alcoholism, compared to back at home; most in the rural areas don’t have access to much in the way of illegal drugs, and cannot afford them.

Saw a 76-year-old man with Parkinson’s; for some reason, he is on carbamazepine, I think for tremor (which is completely the wrong medicine.) He is depressed (common with Parkinson’s), with somewhat of a dementia (also common with Parkinson’s.) I put him on Sinemet for Parkinson’s; he needs an antidepressant, but cannot afford one; next time I will bring in about 4,000 tabs of sertraline ( Zoloft) for depression. They do have mirtazapine available, excellent antidepressant that helps sleep and appetite (good for those with no appetite, who have trouble keeping weight on.)

Another older woman (67-year-old) with epilepsy, since age 15; you can almost tell how long someone has had epilepsy here, as they only have access to the old meds (Dilantin and phenobarbital.) Dilantin causes the characteristic acne and thickened facial skin (among other problems.) And with poorly controlled seizures (common here), you can see that, over the years and decades, the person has lost too many brain cells; they have the staring, vacant look. Very sad. When I have someone who has been on the same meds (Dilantin etc) for decades, I often leave them on it (particularly as they cannot afford the others; although we supply Keppra and Topiramate, both are seizure meds with considerably less side effects than Dilantin.)

I talk with those on meds like Dilantin about oral hygiene, and we give them toothbrushes……and try to get them on a multivitamin, to counteract Dilantin’s deleterious effects, on B vitamins. Some cannot afford the vitamins. Luckily, most get (almost) enough vitamin D, from the sun.

60-year-old man with depression and epilepsy..on phenobarbital…his daughter said he is depressed….blames the depression on the phenobarbital, which it could cause, but probably not….

67-year-old with epilepsy and migraine; says “nobody in my family has headaches”…but the next patient is his daughter, with severe migraines…His daughter has a BP of 180/100, and is on the migraine drug migradrixorina (old drug, very dangerous with her high BP)…..even sumatriptan, which is much safer, is not good in her situation. We will work on her HTN.

Meanwhile: we spent time with the kids in the orphanage next door: the kids are (as would be expected) somewhat needy, like to hold hands. They are generally strong and resilient. On the playground, I watched some bullying, the kids did not cry, did not go to an adult to complain, they take care of it themselves.

Also, the playground is somewhat like ours here in the 1960’s; a bit dangerous, some sharp objects where the kids land, it makes me realize how safe our playgrounds are in the USA.  This orphanage and the grounds are terrific; better environment for the kids than almost anywhere else in Honduras.  It takes so much dedication, hard work, and…money……

We did watch some fellas cutting the grass……with machetes!!!!…and teaching the older kids to do this…..cheaper than a lawnmower……… I saw a 67-year-old preacher, evangelical, with epilepsia…..I could see he would be a great preacher, he was very expressive…. He was on the older epilepsy drugs; I switched him to a newer one, as his seizures were not all that well controlled, and he had side effects due to the older Dilantin. Often we just leave the meds alone, if doing well….

21-year-old with depression since age 13, bipolar with mania. He is on meds, cycles in and out. The mom was in charge of the meds, but she is very mixed up about what he is supposed to take, and can’t tell me what he is supposed to be taking. He has hallucinations, I think he is schizo-affective. I went over a medicine program, wrote it all out, I hope they follow up with us. His family takes care of him, but he is basically a person with unmedicated (and untreated)schizophrenia, along with bipolar.

17-year-old with long-standing moderate chest pain, left side; diagnosed as anxiety; I think it could be reflux; EKG negative (not easy getting tests, actually). I am trying Elavil at night (and reflux med)

44-year-old woman with severe insomnia; worried about her son, who was struck on the head with a machete (he is sort of ok, I think….she cried….said he is back out, working)

60-year-old with epilepsy, cannot afford Valproate (Depakote), I changed him to topiramate (we bring in a lot); with the epilepsy meds, I am trying to get the patient the best medicine that they could afford (in this case, we supply the med.)

3-year-old girl: epilepsia (2 to 3 per month); on valproate; also, a question of true seizure vs. breath holding….I would like to do an MRI, but that will probably not happen; we need blood tests (we will pay: blood tests are expensive, for some reason, most patients cannot afford them)…..Which med is good?: carbamazepine is a possibility, but will need blood tests. She only weighs 13 KG, getting the dose right of these meds is tricky with the little kids……I will follow up with her and mom, or Dr. Dubon (Dr. Dubon is the terrific neurologist who comes to the clinic, and she is an epilepsy specialist)….

14-year-old with 2 to 3 seizures per day, could not afford meds, even the cheaper older ones; I gave him Keppra, as we supply it (and you don’t need blood tests with Keppra)….I would like to do a work up but……..Dr. Dubon’s husband is a young neurosurgeon, he started the first epilepsy surgery program in Honduras, this young boy may be a candidate BUT…it is a long shot…….problem is, with each seizure he loses brain cells….as we see the older people with poorly controlled seizures, we see it in their faces (dulling, blank expression), they come in with a family member, who does the speaking for them. Very sad.

42-year-old with new onset left-sided headache, dizzy, weak; I would like to get some work-up on her, but…..exam is normal, and positive family history for migraine….will treat it as migraine…..and follow up with her (she takes buses all day to get here to the clinica)…..

77-year-old man with new onset top-of-the head headaches, long time cigarette smoker……..new onset headaches are always concerning, particularly at age 77; I would like to get a scan but money is an issue….I will treat, try and get him to the public hospital for a scan (won’t happen: is rural, no money, no transportation.) I worry about lung cancer with mets.

24-year-old with ear pain, then facial weakness/palsy; Possible herpes simplex virus,  … or shingles (Herpes Zoster); will treat with steroids, hope…..

30-year-old man with seizures; wonderful mom, takes care of him….He is on the wrong med, phenobarbital, for his “partial complex”(or temporal lobe)  seizures (phenobarb has it’s assets: cheap, very long-lasting (in case someone runs out of it, or forgets the meds), but it is not good for this seizure type…..I will switch to carbamazepine……

64-year-old man with post-traumatic epilepsy; he did bring in an MRI and EEG (that helps)….will have Dr. Dubon follow up with him……added Ceumid (Keppra), one of the seizure meds we bring in, which is better…….

10-year-old girl with LD, ADD, seizures: cannot afford meds; She had a birth (anoxic: low oxygen) injury…..I do see a lot of birth injuries (not great prenatal care, nutrition a problem, and cannot get C-Sections easily.  If a woman needs one: C=Sections have gotten a negative reputation (“overused in the United States”), but they often save lives and brain cells……..I gave her Ceumid, and tutoring would help but not easily available…..support services are lacking….they do try their best.

I saw, with Dr. Dubon, a brother and sister, 15 and 17-year-olds, with an unusual hereditary ataxia and neuropathy (coordination problems, due to cerebellar degeneration; there are many genetic variations; you can trace in many generations)…unfortunately, the young woman is fairly severe, with a tremor (cerebellar “action” tremor), and very poor gait….she will be in a wheelchair at some point.  I spoke to the wonderful mom for a long time, gave her some hope (there is some), she cried and cried….it is heartbreaking…..even here, there is not treatment, just better supportive care and physical therapy…

Interestingly, one of these kids, on exam, had increased reflexes, the other: decreased. That is unusual (usually with hereditary syndromes, physical findings are pretty much the same…..The family (unusual for our clinic) has some money, can get some physical therapy in the main city (Tegucicalpa)….

I saw an unfortunate 39-year-old with frontotemporal dementia (unusual at her age); she has a flat affect, performs poorly on a mini mental status exam; this began 2 years ago. Her sister takes care of her. Family says she was “always a bit odd, emotionally and personality wise”…..Often the families just take care of the other family member with severe medical or psych problems; there are not a lot of public institutional options.

60-year-old man with daily cluster headaches (unlike migraine, which is 3:1 women to men, clusters are more in men: about 1 in 250 men have clusters, about one in 700 women.) He cannot afford sumatriptan, but we gave him 27 of them.  He can return for more. I put him on verapamil, but he may not be able to buy it….

Dr. Dubon’s husband Rafael, the young neurosurgeon, was with me: just in time: I saw a 20-year-old with epilepsy; the CAT scan showed a lesion on the right side, and he has focal-localized right epilepsy; maybe he is a candidate for epilepsy surgery. At least we now have him on some epilepsy meds, they should help….

I saw 2 sisters, 30’s, with familial hereditary trigeminal neuralgia; this is unusual, but occasionally you see it. I put both on carbamazepine for it, hope it helps; unfortunately, with this drug we should, in theory, get a blood test.

I have my neurology books on my I-Phone, it is easier to have regular good ol’ books, more convenient……

Dr. Dubon is treating my patients, and me hers: she writes in Spanish, I scribble in English; we sort of work it out. Her handwriting, at least, we can read; mine is doctor-type chicken scratch……

I saw a 20-year-old whom I had seen before; she has epilepsy, was well controlled on the type of Keppra (seizure med) I brought last time from the U.S..  She got a different type here, and it does not work (this occurs also in the U.S., where different generic epilepsy meds have varying degrees of bioavailability, and one may not work, while another one does: we try and stick with the brand that works). This woman has her seizures at 12 AM, so I am timing meds to peak at that time.

I saw: 2 people with head injuries after falls, and one woman who had been shot in the face (robbery). She recovered, sort of, but is very depressed…….not a lot of support in her family……

I saw a # of women who have 4 to 6 kids, where one or 2 have died (various reasons: often an infection). These women are so so resilient and terrific; they persevere……

In Honduras they use a drug, propranolol, “as needed” for headaches; in the US, we usually use it daily as a preventive.  BUT, it seems to work for some, and it is a cheap drug. I saw a sad situation: 43-year-old, heavy(300lb) man, 5 years earlier, he dove into the river, striking his head, and is paraplegic (C6-C7 injury); He only recently got a wheelchair, where he can go outside; he is stuck inside; he is accompanied by a wonderful wife, they have 2 teenage kids. I spoke to him quite a bit about weight loss, am trying to get some physical therapy, but he is isolated. He is a computer specialist, can work from home.

Until next time…………adios…..

Larry R.

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