Smartphone-Based EEG as a Screening Tool for Status Epilepticus in Patients with Altered Mental Status in a Zambian Hospital Part 2

Morgan Prust, M.D. 

Resident in PHS Neurology 

PGY-5

February 15, 2019

Working in Zambia, or in any setting where the medical need vastly exceeds the healthcare system’s capacities, one is witness to a heartbreaking amount of morbidity and death that would be preventable in any hospital in the developed world. In-hospital DVTs are very common, owing to prolonged hospital stays and a lack of DVT prophylaxis. Because routine labs are not checked on a daily (or even weekly) basis for inpatients, electrolyte abnormalities are widespread, and lead to renal failure and fatal cardiac arrhythmias. In neurology patients, however, aspiration pneumonia poses a particular challenge.

At BWH and MGH, all stroke patients are mandated to undergo a swallow safety evaluation, and patients fail this, they are evaluated by an SLP specialist, and, if needed, given modified diets, placed on aspiration precautions, and in advanced cases, fed exclusively through an NG tube. None of the infrastructure exists for this level of care in Zambia, and at UTH, aspiration pneumonia is tragically high in neurology patients in general, and stroke patients in particular. This arises from a number of contributing factors beyond the traditional organic risk factors like altered mental status and oropharyngeal dysphagia.

Patient's head of bed propped up by clothing
and personal possessions

First of all it takes tremendous effort simply to elevate the head of the bed here, as the beds have no mechanism for inclining the mattress. One's best bet is to find a box, when available, to place under the mattress. When no box is to be found, the belongings of the patient or their family can be used, though this is sub-optimal for self-evident reasons, and there's no standardization of this practice to make it happen as a matter of course. There's also a cultural emphasis on food as being central to the healing process, and families will feed their loved ones regardless of how obtunded or dysphagic they are. NG tubes are available but have to be purchased by families, and X-rays, hard enough to come by for patients with pneumonia and respiratory failure, aren't used to confirm placement. There simply isn't enough nurse care to allow for supervised feeding, and all of the feeding is administered by family members who are generally unable to recognize clinical signs of aspiration. There is no institutionalized practice of swallow screening and no SLP specialists. So, taken together, the risk of in-hospital aspiration is very high.

My project for this trip has been to catalog the feeding practices for stroke patients (while doing my best to optimize adherence to standard aspiration precautions), and follow them throughout their hospital stay to determine who develops aspiration and who doesn’t, with the hope of identifying key modifiable risk factors that could be targeted. My hope is that these data can be used to justify the implementation of standardized and concrete aspiration preventive measures, and be used as a baseline to judge the efficacy of those measures. The simpler and cheaper an intervention is, the easier it is to adopt, implement and scale. It is amazing to think of one day being able to give tPA for acute strokes at UTH, but for now, so many more complications and deaths can be prevented by addressing much lower hanging fruit like preventing aspiration pneumonia.