Neurologic Care at a Referral Hospital in Zambia

Jeffrey Gluckstein, M.D. 

Resident in neurology at BWH/MGH

PGY-3

February 15, 2019

I’m currently working on the neurology service in a referral center in Zambia. There are three Zambian adult neurology residents and only one attending supervising the inpatient clinical services at any given time. With nearly 1700 patients in the hospital, the neurologists are stretched thin between the wards, ICU, clinics, and consults.

I chose to spend four weeks in Zambia because I wanted learn to provide neurological care in a resource-limited tropical setting. So far, my PGY-3 neurology colleague from Rush and I have focused on recently-admitted inpatients. My typical day involves entering a room with 48 male patients and literally walking from bed-to-bed to determine whether patients have neurologic problems. I write notes and give my thoughts to the families, interns, and nurses. I repeat the process in the female ward, eat a late lunch, and check in on consults and old patients scattered around the hospital in the afternoon. We typically spend about 9 hours in the hospital before coming home for a quiet night.

In my first week I saw 44 new patients and discussed many more with my colleagues. 11 were ischemic strokes, 7 were intracerebral hemorrhages, 7 were seizures, and 4 were CNS TB (either meningitis or tuberculomas). To keep things interesting, we also saw likely metronidazole toxicity in a patient with undetected AKI and 2.5 weeks of antibiotic therapy, severe hydrocephalus in previously undiagnosed neurocysticercosis, and a case of clinically diagnosed Morvan syndrome now responsive to IVIg. The average patient age was 48. While infectious diseases bring the majority of my young patients to the hospital, a surprising number have intracerebral hemorrhages and ischemic strokes without a clear underlying cause (through the resource limitations make the hunt for a definitive diagnosis difficult).

All charting is done on paper - and I mean all of it. Old notes from previous admissions or clinic visits sit in a stack at the bedside. Test results have to be manually retrieved by nursing from the laboratory and stapled to the chart. Discs of cross-sectional imaging are added to the chart with a paper copy of the radiology evaluation added 1-2 days after the scan is done (for patients wealthy and stable enough to obtain imaging at an outside facility, as the hospital’s 2 CT scanners and 1 MRI are both broken at the moment). Orders are entered in notes and the medication administration record, but often aren’t acted upon until the busy nurses have the chance to review them, deliver a paper prescription to the pharmacy, and bring back a medication. 

Despite the resource limitations and my lack of familiarity with neuroepidemiology in Zambia, I feel that an American neurology resident can be useful here. The hospital is absolutely deluged with neurological illness, so there are many patients who would wait a long time to be seen by a neurologist without me looking at their chart, asking for their chief complaint, or simply spotting a neglect or gaze palsy from across the room. Neurophobia is probably more prevalent among interns than in the United States, so identifying deficits on exam, explaining a diagnosis to a patient, or slightly modifying care plans can greatly advance management. Of course, I’m learning an incredible amount from the trainees and practicing neurologists here. CNS tuberculosis or cysticercosis are rare cases in Boston, but they’re becoming my bread and butter. Perhaps more importantly, I’m learning to trust by history and exam more completely, as diagnostic testing can take days and patients often need urgent treatment based on clinical diagnoses. I hope to become even more helpful as I become more familiar with local epidemiology, the available medications, and our limited diagnostic tests.