First Encounters at Pantang
Entering Pantang Hospital’s iconic main building, I hear indecipherable shrieking and commotion reverberating from upstairs. Moments before all appeared calm and at ease as student nurses played competitive early morning football before the heat would become unbearable on a nearby patchy grass pitch. Walking up the stairs to the first floor consulting rooms I wonder just what will I encounter today.
Yesterday there was a chiseled young man stripped to the waist with cuts and abrasions over both arms, laid out on a stretcher on the first floor landing in front of day patients and their relatives sat on benches waiting patiently for a consultation. Despite lying on his back, the man’s presence and absorbing eyes commanded all attention though I consciously avoided contact as I passed, unsure of becoming involved in the new environment that I had only arrived in the night before. By the time the somewhat over-relaxed medical assistant came to interview the man who had fought the law, lost and been brought to hospital, he was more subdued from the effects of an intramuscular sedative. Still his personality held sway as a number of by-standing young nurses giggled embarrassingly and my new colleague remained standing at his feet, motivated more by maintaining an arms-length distance than asserting a commanding authority.
Fortunately, this time the sound was that of a large television that filled the waiting area air with the car-crash soundtrack of a syndicated American crime documentary that no-one was watching. Like yesterday, many of those attending will have travelled long distances to reach Pantang, on the rural outskirts of Ghana’s capital Accra. This is one of only three psychiatric hospitals in the country and cares for some 700 in-patients and several more annually in its out-patient department. While some will have been ‘recommended’ to attend by the police or the courts, most are coming for follow-up reviews and prescription renewals. For many though their day will have started well before their arrival which is anytime after 7 AM and will have involved travel by tro-tro, the local public transport of converted minibuses. And by then, those getting out of the rammed people carriers and their stop-start negotiation of oncoming traffic on unmarked and often unsurfaced, potholed roads may understandably be in need of a psychiatrist.
Having observed the clinic of a medical assistant (known as MAs) yesterday and checking in with Dr Dzadey, the Polish medical director and only non-Ghanaian permanent member of staff, I agree to see some patients of my own. Usually out-patients would be seen by one of the three appointed MAs, who are usually nurses with additional training that permits them to assess, diagnose and manage patients independently. Before patients see an MA though, each will have had their observations (pulse, blood pressure, temperature and sometimes respiratory rate) recorded by the out-patient nursing staff. If they’ve been here before, their patient file will have been pulled from medical records in time for when the MAs arrive around 9 AM. The clinic will then continue until the last patient is seen which may be early evening though usually the nurses ensure that this is well before their shifts ends at 5 PM.
I soon discover that many attending are seeking nothing more than a prescription renewal. They’ve been stable since their last appointment and often several attendances before, as shown by the previous clinical entries confirming continuation of their management. Many patients seem to placidly accept their need for medication though for some there is an adverse event recorded about what happened when it was omitted. Still I’m struck by how compliant many of them are though some do appear likely to have an underlying psychosis. Others though seem free of psychotic symptoms while on relatively small doses of an antipsychotic, usually Chlorpromazine. After completing one typical middle aged woman’s prescription request, she tells me that my next set of notes is her brother’s. After acknowledging that detail, I realise that she’s come alone to collect his prescription as well. She assures me that her brother have no concerns either and I give her a 60 day prescription for him as well, adding that if he would like to see me while I’m over, I’ll still be here in two months time.
Other cases feel more rewarding in terms of providing reassuring guidance over the presence or absence of mental illness. I’ve rarely treated malaria before but am asked to assess a shy 21 year old girl whose behaviour was bizarre a month ago when unwell with malaria for the first time. The treating medical hospital advised her father to bring his daughter here for psychiatric review and he would like her to have a tablet that will stop it happening again. However, I feel confident that she had a fever-related delirium, which providing the malaria is treated doesn’t need psychiatric treatment. I thus write an open letter to that effect for them to take away and after it receives the rubber stamp of the social services office (the only stamp available in the hospital), the father leaves satisfied with their visit.
A more surprisingly familiar presentation is that of a 25 year old graphic designer who’s become preoccupied with a relationship between a friend and a girl he knows. Accompanied by his exasperated brother who insisted he come, the man acknowledges the problem and concerns about not being interested in women. There appear to be depressive symptoms in that he’s not sleeping nor eating and has lost weight but that could be due to schizophrenia as well. As there’s an expectation in clinic that each consultation concludes with a primary diagnosis according to the International Classification of Diseases (ICD-10) I diagnose an acute psychotic episode due to the extent of his recent persecution and prescribe an antipsychotic. His brother is grateful for something and agrees that my other recommendations such as gentle exercise and socialising are reasonable. It’s only when the patient becomes guarded at my suggestion that perhaps he limits his time spent on computers that I realise the likely presence of autistic traits; characteristics that have influenced both his vulnerability to existential concerns and achievement in his chosen line of work.
My last patient is a boy of 8 who attends with her mother. I haven’t seen paediatric cases in years, much less dealt with cases of epilepsy but these are among the client group that the clinic looks after as well. In most developing countries there is no neurology service so psychiatrists also treat epilepsy and other brain disorders. This may ensure for more rounded psychiatrists but also creates an association between the neurology and mental illness (or madness) that reinforces stigma for both conditions. While the boy has been treated elsewhere, he hasn’t been here before so no notes are available and as is ever the case with epilepsy, getting detailed information is both challenging and essential. The boy doesn’t speak or hear and his mother only speaks the local language of Twi. The MA from before helps with the interview though I don’t realise until later that his translation isn’t completing reliable. Then the mute, dazed looking boy quietly shouts and makes some grabbing movements towards the room’s examining couch. He appears to be falling over, so we lower him to the floor and he starts making leg flexing, bicycle movements that are typical of a partial seizure. That’s plenty of information to go on and I take the case to Dr Dzadey for discussion of the local management.
The boy’s situation now has the sympathy of my MA colleagues who see how Dr Dzadey questions the mother with the assistance of a member of staff who speaks more fluent Twi. A management strategy of anticonvulsants, provision of mosquito nets to reduce the risk of future epilepsy-aggravating infections and review in a month’s time is agreed. While a CT brain scan would be ideal, as with most medical recommendations in Ghana, the patient (or family) has to pay. As the mother says that when he was first unwell three years ago with likely meningitis and underwent a scan that found no abnormalities, Dr Dzadey suggests this can wait though the mother is given a CT request form should she want to pay for a scan.
The three MAs and myself then meet as a group for the first time with our boss to discuss how future reviews of their work will run. However useful I may be directly to the patients attending, my main role here is to improve and possibly inspire the clinical skills and management of the MAs, as this will leave behind a more lasting legacy. Three days in and although the environmental conditions are new and on a different continent, the clinical material is remarkably familiar. Next week though, my proper work begins.
Note: for patient confidentiality some details have been changed
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