Smartphone-Based EEG as a Screening Tool for Status Epilepticus in Patients with Altered Mental Status in a Zambian Hospital Part 1

Morgan Prust, M.D.
Resident in PHS Neurology
PGY -5

I arrived in Lusaka, Zambia in early October 2018. This was my second trip to Zambia in residency, my first having been last year, when I spent a month working as a general neurology consultant at the University Teaching Hospital (UTH) in Zambia’s capital city. That experience helped catalyze my interest in global health, and I felt so fortunate to be able to go back. I returned this year to help take care of patients, collect data for a stroke-related research project, and help out with the early stages of Zambia’s first ever neurology residency, which officially got underway a week or so before I arrived. As was the case when I was in Zambia last year, it’s been an incredible experience, marked with the highs and lows of practicing medicine in a low-resource setting that has an astronomical burden of neurologic disease.

Zambia is a landlocked country in southern Africa, sandwiched between Angola, Congo, Tanzania, Malawi, Mozambique, Zimbabwe, Botswana and Namibia. It is a former British colony which gained independence in 1964, and has had a peaceful and relatively stable existence, although its economy is precariously tied to the country’s copper trade and its fluctuating fortunes. It has a population of about 17 million, and Zambia, like many of its neighbors, was hit particularly hard by the HIV epidemic. While HIV treatment and prevention have significantly improved overall life expectancies over the past 20 years, the rate of adult HIV infection in Zambia is still about 13%, and is the population’s greatest driver of mortality. HIV is associated with a broad spectrum of neurologic diseases that comprises a subspeciality of neurology in itself. TB meningitis and complications of CNS opportunistic infections are exceedingly common (it is more common for patients to present with multiple concurrent CNS OIs than a single one). Epilepsy is very common, owing to the high rate of brain lesions from CNS OIs and other neuro-infectious diseases, and poor access to specialized care/AEDs for patients with primary seizure disorders. Beyond the realm of HIV-associated disorders, stroke is the eighth leading cause of mortality, and speaks to a high prevalence of untreated hypertension and diabetes.

For Zambia’s 17 million people, there are four adult neurologists (and now three Zambian neurology residents). They all practice at UTH in Lusaka (with the exception of a pediatric neurologist who practices in a smaller city called Ndola in the country’s Copper Belt region). The launch of the residency program will hopefully allow the specialty to grow in a country that sorely needs more neurologists. There is also a steady flow of expat neurologists and neurology residents like me who come to work for a month or two a time, owing to the presence of the American neurologists who work and live there full time. I work primarily with neurologists Omar Siddiqi and Deanna Saylor as my attending mentors. Omar is based at BIDMC, but primary lives and works in Lusaka and has been supervising visiting neurology residents for many years. Deanna, who arrived in Lusaka earlier this year to head the new residency program, is a neuroimmunologist/neuro-ID specialist from Johns Hopkins.

My typical day involves getting to the hospital around 7:30am. I round on all the neurology patients in the ICU, which has about 15 beds and seven ventilators. Common reasons for neurology admissions to the ICU include cerebral hemorrhages requiring extraventricular drains, status epilepticus requiring sedative doses of AEDs, and neuro-infectious emergencies. After rounding in the ICU, I pass through all the inpatient wards and the emergency ward to see any new stroke patients and to follow up on all known stroke patients for a research project I’m doing on aspiration pneumonia and stroke (see next post). In the afternoons, I typically continue seeing patients, either stroke patients or other non-vascular neurology consults, and staff cases with Deanna and the other neurology residents.

Exterior and interior of the UTH intensive care unit

 CT is the predominant imaging modality, owing to its relative ease of access, and to the fact that the hospital’s MRI has been down since this past spring (patients with private funds can go to one of the local private hospital’s for an MRI, though the image quality is generally poor). it’s very difficult to get any vascular imaging other than carotid ultrasound, which significantly limits the ability to diagnose the cause of an acute stroke. We have an electrophysiology lab here, which has EEG (including a portable EEG workstation that can be wheeled to patient’s bedsides) and EMG. Lumbar puncture is very often indicated but are not infrequently refused by patients or their families due to a widespread misperception that LPs cause death. This stems from the story of a former politician with an advanced neurologic illness who died coincidentally shortly after undergoing an LP. When we do get LPs, the results have to be interpreted with caution, as the accuracy of the laboratory’s CSF assays is inconsistent (for example, the RBC count will often be quoted as 0 despite a tap with gross blood).

Here are some images from some of the patient's I've been taking care of:

Multifocal left parietal tuberculoma in a patient with poorly controlled HIV

Multifocal lesions in 42F with CD4<10 o:p="">

Overall, it’s been an incredibly gratifying experience to be here once again. I feel so grateful for the opportunity to use the skills I’ve learned in residency in a place where the need is so great. There are days when the volume of tragedy weighs heavily, but the joys of working with amazing colleagues and universally lovely and grateful patients, and getting treat complex and fascinating neurologic illnesses make it so worthwhile.