Honduras Journal #5

Larry Robbins,M.D.
(Note: The patient stories have been changed somewhat, to protect identities)

I brought in about 26,000 tablets. These consist mostly of Keppra(for seizures), topiramate(for seizures and migraines), and various psychiatric medicines. I also supply plenty of sumatriptan, for migraines. Our major challenge is in keeping enough Keppra in stock. It has been marvelous for many of our epileptic patients, much better than the older (Dilantin/Phenobarbital) meds. However, if we run out of Keppra, it is not good, as people start having seizures again. So, I often write 2 scripts for the Keppra: 1 for our clinic(free), and 1 for an outside pharmacy. The problem is, most cannot afford it at an outside pharmacy.

The psychiatrist on our staff, Laura Mendoza,M.D., was there this time. There are relatively few psychiatrists in Honduras.
They often are overworked and overwhelmed. Dr. Mendoza is excellent, and she just graduated. Dr. Mendoza also teaches in the main city, Tegucigalpa. We end up treating the same patients; the main difference is, her notes are very legible, mine aren’t. Now that we have 3 or 4 doctors’ notes on the same patient, in 2 languages, it is becoming more difficult to decipher the chart. Also, as we see patients for the 5th or 6th times, we have a thicker chart, and determining the current meds becomes more challenging. So, we are instituting a cover sheet for diagnoses and medicines, much as I do in the Chicago office. The charts are reasonably organized. It helps being on paper (not electronic) charts.

Along with the psychiatrist, the plan is to begin doing psychotherapy as well. We have a psychology intern for 6 months, and then another is scheduled. So, we will refer some patients for therapy. There is great need for psychotherapy. Many of our patients are women with anxiety and/or depression. They have nobody to turn to, and tend to be stoic. This is somewhat cultural. The woman is often the matriarch, and is supposed to be stoic, even in the face of devastating loss. One 38 y.o. woman started to cry when I asked if she was depressed. Her son had been killed by a machete. Another 42y.o. woman had just lost her husband to a heart attack.
These women have nobody to speak with, and they still have to take care of the kids and home. They often work outside the home as well. We have quite a bit of Prozac and Zoloft, so at least from the medicine end we are somewhat covered.

In third world countries, much of the psychotherapy is accomplished by relatively untrained personnel. Our plan is to involve Luci, the nurse who runs our neuro clinic. She will do online therapy training. Then she can talk, and support, some of the women who so desperately need a sympathetic ear. For instance, I saw another woman, 39 y.o., with new onset daily headaches. These began after losing her dad, with whom she was very close. I put her on amitriptyline at night, which can help both headaches and moods. If we can get her into some type of therapy, even a few sessions, it may make a difference. I saw a 73 y.o. man with epilepsy, as a follow up to our initial visit. He is much better after switching to Keppra; our challenge now is keeping enough Keppra in stock. He also has orthostatic hypotension, which is low blood pressure standing up. Treating this is tricky. If you raise the blood pressure, particularly at advanced ages, you risk going too high on the
pressure, with all of the attendant issues.
I had a 62 y.o. woman come in, with early Parkinsons. We do have Sinemet (a form of levodopa), that will probably help for 2 to 7 years. The family brought in (2 nd visit) a 17 y.o. young man from the main city, Tegucigalpa. He has POTS, depression, and migraines. POTS is relatively common among young people with migraines It is a condition of “autonomic instability”, where the pulse races on standing. Dizziness is also common with POTS. The “autonomic, automatic” nervous system is just very sensitive, and overreacts. Luckily this often improves, or resolves, by age 22. He was improved after we had stopped some of his previous medications. Like many (most?) 17 y.o. young men, he did not want to see a psychotherapist. Adolescent boys are very similar whether they are in Tegucigalpa or in Chicago. You interpret teenage boy grunts, because they certainly don’t talk very much.

There was an 18 y.o. young man with seizures, who had been well controlled on the Keppra we brought in from the U.S.. We had run out of Keppra, and the parents bought local Honduran Keppra. He then had seizures again. This happens here also, where a change in epilepsy brand leads to seizures. This was always an issue with generic Dilantin (and in Honduras, due to cost, Dilantin is still the #1 epilepsy medicine).

I did see several other Parkinsons patients, both in their early 80’s. We supplied them with the main med, Sinemet. It at leasts gives them 8 hours of functionality during the day. I brought in 2,000 tabs of Sinemet, which should last 4 months. I saw a local Pastor in follow-up, a wonderful 52 y.o. man. He has migraines, and a severe “essential, familial” tremor…he does exercise a lot, primarily at the gym. There are not many gyms or health clubs around. I had previously placed him on propranolol, a med that can be beneficial for both the migraines and the tremor. Sumatriptan was helping once he has a migraine. The propranolol is helping, but he is tired, so I lowered the dose.
I saw 2 women who recently had suffered major losses. We theoretically have a psychology intern with us for 1 year.

Adding some type of psychotherapy, rarely seen in Honduras, will be a major help. I have now seen some patients 4 times. This gives me more of a “feel” for that person. I set up this clinic for long-term care, not as a quick one-time fix. In that sense it is patterned after my headache center in the States.
We are building out a small “neurology-psychiatry” section of the larger medical clinic. Getting our own Neurology cabinet was a major step. Luci (nurse) will have an office, and a small computer. These things, taken for granted back home, are luxuries here.

I saw a 40 y.o. developmentally delayed woman with decreased appetite, weight loss, and depression. I want to find an antidepressant that can stimulate appetite. We have several possibilities that we stock here (amitriptyline, quetiapine or risperdone, or even mirtazapine). Mirtazipine is a marvelous antidepressant that helps sleep, and causes weight gain: so, for those with difficulty keeping weight on, who don’t sleep well, mirtazapine can be excellent.
I tell those with epilepsy, who are on Dilantin, that they have to brush their teeth. Dilantin, an old epilepsy med, is rough on the gums (long-term). One man said he “never brushes because my brother said it’s bad to brush”. Another said she “can’t afford toothpaste”. For those on Dilantin, I also push taking a multivitamin; most can afford those.

I had placed a woman on Topamax (a seizure med) for her migraines; when she came back in, she said “I never started it, it is for epilepsy’. That is why I try to explain, in the beginning, that we are using a particular drug for headaches, but it is originally used for something else(depression, epilepsy, HTN, etc.). Overall I observe a higher medication compliance rate in Honduras than we observe here.

A 77 y.o. woman came in with her 2 daughters(who take great care of her). She has dementia, Parkinsons, and tardive dyskinesia. Tardive dyskinesia is a movement disorder, caused from certain psychiatric meds(mostly the antipsychotics). I gave her Parkinsons medication. Then, on the way out, the daughter says “doctor, can you check my head, I fell and hit my head 2 days ago”. They live 4 hours away. I did a neuro exam, which was normal. Even if I wanted to obtain a CAT scan, it would not be possible.

I saw a 28 y.o. woman with hereditary spinocerebellar ataxia: it runs in the family, and results in: poor coordination, problems with balance, severe problems walking, and other issues. She also has low back pain. Her brother, also a patient, has the same thing (along with migraines). They have a wonderful mom, who looks after both of them. Dr. Dubon (neurologist at our clinic) also sees the young woman.
Unfortunately, even here in the U.S. all we can do is supportive care for this condition.

I have an 18y.o. patient with epilepsy, who is much worse off since he was thrown off of a motorcycle. He now has a traumatic brain injury, among other issues. There are a lot of motorcyclists here. The roads are treacherous for motorcyclists, with many accidents. We just don’t have the rehab type resources here in Honduras that are available in the U.S..

I saw a 29 y.o. woman with migraines, neck pain, and depression/anxiety. Her brother died 2 months earlier. She has 2 young children. I placed her on sertraline(Zoloft), which we supply, and also sumatriptan for the migraines. At least the sumatriptan has been keeping her severe migraines at bay. We have a major challenge with the X-Ray machine in the clinic. It does not work. They manage to staff a 24 hour mini- ER, seeing emergencies from 100 miles around, with no functioning X-Ray. I spent time in the clinic with a wonderful X-Ray expert from the States, who devotes his time to clinics such as ours. The major question is whether to put in digital(new but more expensive) vs. fixing the old, tottering system. The other major issue is fixing up the X-Ray room to code (which may involve expensive leaded walls).

The administrative, nursing, and medical staff do a wonderful job. They work long hours for modest pay. This clinic delivers 330 babies per year, with no facilities for a C-section. If the mom or baby are in trouble, the family has to scramble to bring them to Tegucigalpa, not an easy trip.
We are paying for labs for certain patients. For the epilepsy patients, obtaining blood levels of the anticonvulsant medication is often helpful.

Most of the time we can get by without blood testing, or MRI exams. Blood tests are expensive in Honduras. The lab person in our clinic is independent, and he does the tests right there. The equipment is a bit old. Still, I am grateful that we can obtain labs on some patients. For
others, I will write a lab slip, and sometimes they can afford to have the testing at an outside lab. Occasionally they can get testing through the public health service, but I am never sure how or when that works. Our EEG tests are on hold, until Dr. Sophia Dubon (young neurologist/epilepsy expert) comes back. She is on a year leave to study epilepsy in Brazil. We may be the only clinic in the country that has EEG capability(outside of the few big cities).

We do see a lot of head injuries, and trauma; this leads to headaches, epilepsy, and psychological issues. It “takes a village” to help traumatic brain injured patients. Unfortunately, the “other villagers” are scarce here in Honduras (villagers being: physical therapists, psychotherapists, rehab specialists, etc.).
What strikes me is the strength of the Honduran moms. There is violence in the country, but the main problem is poverty.
We have our neurology-psychiatry medicine cabinet within the main pharmacy. Luci (neurology nurse) does an inventory, and emails me as to how many pills, of which medicine, are available. I order more medication here in the U.S., and have someone bring it over. I also carry in tens of thousands of pills when I come in. The soldiers manning the TSA positions at the airport are very nice. They only went through my bags one time, because the dogs were sniffing like crazy. They realize people don’t usually sneak contraband INTO Honduras.

We bring in thousands of myasthenia gravis medications. The medicine(Mestinon) is very effective, but few in Honduras can afford it. If I bring in 6,000 tabs of Mestinon, the 38 myasthenic patients can function much better for a # of months. Without the Mestinon, they are too weak to do anything.
At times, there is a lot of unrest in Teguz(the main city). I was going to do some teaching at the public hospital the next visit, but it is too dangerous right now. I am trying to get the neurology residents to come on out to our clinic, but it is not an easy trip.

I had a 15 y.o. young man with epilepsy come in. He is much improved since we switched his epilepsy medicine to Keppra. It is difficult for the family to obtain the Keppra, as they live 3 hours away. They cannot afford to pay for it locally. I discussed a back-up plan, if or when they run out. That would involve going back, temporarily, to the old medicine, Dilantin (which is cheap). That plan is tricky. When we switch from one to
another, it is not easy, and breakthrough seizures may occur. My 36 y.o. epilepsy patient said that her 16 y.o. son “has a tumor”. The son was diagnosed with some type of tumor, but no tests were run. We tried to convince her to take him to the public (free) hospital in Tegucigalpa. That is difficult, and just getting there is an all day affair. You have to go there to wait in line to make an appointment for a future date. They don’t take appointments over the phone.
I had several migraine patients come in, where the meds had been ineffective. These patients are willing to keep trying, and are grateful for any help. Unfortunately, at best we can adequately help 70% of the headache patients.

I saw a 4 y.o. boy with a shunt in his head for hydrocephalus (too much spinal fluid in his brain at birth). I am managing the epilepsy medicine. The challenge is in finding liquid medicine that is affordable. We have the little boy on oxcarbazepine liquid, which controlled 80% of the seizures. After we added Keppra, and the seizures were almost completely controlled. The mom has other children, financial issues, medical issues of her own, and yet she takes wonderful care of this little boy.

There is a 29 y.o. man with seizures and possible schizophrenia. His mom cannot read. The medicines are complicated, so we went over them 4 times. They don’t have a cellphone, but next time will bring someone else along. The problem is, to get to our clinic is a 2-bus, all day affair. I saw 2 patients with similar problems: active seizures, plus anxiety and depression. The issue is whether the SSRIs (Prozac,
Zoloft) are safe with epilepsy. The answer is murky. One patient has fairly severe depression, so I did start the Prozac.

This trip we had with us a wonderful U.S. doctor, Morris Maizels. He added quite a bit of headache expertise. Neither of
us are fluent in Spanish (we limp along), but the interpreters are great.

I saw a 40 y.o. woman with epilepsy, migraine, and depression. She is on no meds. I put her on Keppra and Zoloft, which hopefully will help several conditions. Ideally we would have her see the psychotherapist, who is starting to work at
our clinic.
I had a 50 y.o. man come in, on Dilantin for seizures since age 5. He had poor gum health, commonly seen with Dilantin. Also, his coordination was off, which is also observed with long-term Dilantin use. I am trying to switch to Keppra, but we may end up back on Dilantin. I emphasized the need to brush his teeth 3 times per day.

A 13 y.o. young man came in, supposedly in the 6 th grade. However, he is out of school for unclear reasons. I think it is because he is a slow learner, with learning disabilities. He is depressed, probably because he is bored all day at home. Mom has depression, a past history of a suicide attempt, and she also had a stroke. The young man is mad at his mom for various reasons. I am trying to have him re-enrolled in school. There are no resources available for his LD issues.
I had a 62 y.o. woman with muscular dystrophy come in. We discussed exercises that she may be able to do at home. I saw a 60 y.o. (very nice) farm worker, with epilepsy and migraines. To limit meds, I chose Topamax, which we supply to the clinic. Hopefully this will help both conditions. He has carpal tunnel on one side, and an ulnar neuropathy (“funny bone”) problem on the other. I went over suggestions for these
conditions.

I had a 3 y.o. little girl come in with her mom and dad. She is on liquid Dilantin. Mom has epilepsy. She had only 2 seizures, both associated with a high fever. Despite the genetic family history, it is possible that she may not require long-term epilepsy medication. It will be helpful to obtain an EEG.

I encountered a 7 y.o. young man, who is acting out at home and in school. He had sexual abuse at age 3. I would love to get him into the therapist, but that may not work out. We do see a lot of abuse here. Early abuse(0 to 3 years old) leads to major problems later on.
We see a lot of: TBI(head injuries), birth trauma, spousal abuse, and the results of violence. We also observe many loving families and parents, and 3 generations living together at home. In the U.S., there is very much isolation. We have an isolating society, for all ages, here in the States. I see less of that in Honduras.

……adios……..till next visit……Larry Robbins,M.D.

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