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The Royal College of Psychiatrists Improving the lives of people with mental illness

Pantang Hospital

Pantang Hospital
My head is still spinning a bit at being here. It is just so very, very different from the UK. It is currently not as hot as I had feared - we are just coming to the end of the rainy season and it is only about 28 degrees, but with 80-90% humidity, it feels much more uncomfortable. There are hardly any mosquitoes around Pantang which is a big relief. I feel very conspicuous - I can feel curious eyes on the new white lady doctor (who also has elbow crutches, just to attract additional curiosity) wherever I go. But I also receive a warm welcome and constant greetings. I am trying to learn some basic Twi.

Ambrose has recovered, so our work together can begin in earnest. We work by seeing patients in tandem: Ambrose takes the history and mental state, then I sometimes interject with some more questions/clarifications and then we do any necessary physical examination and formulate a care plan. I was heartened by Ambrose’s basic history taking and mental state examination skills. We began to work on being a bit more focused about his line of questioning, always keeping in mind what he was trying to rule out or rule in. I also began to notice the tendency here to often prescribe more than one antipsychotic at a time, with patients often receiving “booster depot injection” doses of antipsychotic at clinic if they had any psychotic symptoms, even if they were fully concordant with their oral medications and there was room to put up their oral doses. There seemed to be a perception that giving an injection as opposed to a tablet was somehow more “potent” than oral medication. We had a short discussion about this in clinic, but i think it is quite an engrained practice and I made a mental note to cover safer prescribing practice at one of our formal teaching tutorials which I will be holding on Wednesday lunchtimes.

After lunch we had to split up and see patients separately - this is obviously contrary to the spirit of the project, where everything we do should be with an MA/nurse to ensure the passing on of knowledge and sustainability once we are gone. Having said that, it is easy to say that, but less easy to stick to when the outpatient corridor is heaving with patients, some of whom have travelled hours to be there, and there are only two clinicians to get through them. In addition, seeing all the patients as teaching cases inevitably slows down the pace. I know that we will be getting more staff in a couple of weeks, and until then I will just need to try and split my time sensibly between service provision and teaching.

In my afternoon clinic, I see a man in his 50s, who is brought in by his sister. He has a long history of alcohol use, and some 4 days previously he had apparently been admitted to a medical ward with a withdrawal-related seizure. His sister brought a letter from the general hospital, addressed to psychiatry, saying that some time after admission, the man had become “aggressive, hallucinated and uncooperative with treatment” and so they had had to discharge him and could we treat his “psychiatric problem”. The most striking thing was the man had been sent home with a bag full of all the medications that his family had bought for him on admission, but had not been administered, including about 12 glass phials of IV Thiamine. The man was very ataxic, delirious and had Wernicke’s encephalopathy. I felt upset at the way the other hospital had treated (or not treated) him and I spoke to Dr Dzadney for advice; she was not at all surprised by this type of presentation and she told me that any form of mental disturbance, even if there is a clear physical cause, is felt to be the remit of psychiatry and that we should admit him for treatment, but warn his family that we could only keep him for a maximum of three weeks and that he might possibly have irreversible brain damage. We kept him for about a week and gave him IV thiamine etc and fortunately he made a full recovery.

On the Tuesday afternoon we managed to go to the in-patient wards to do some reviews. The ten wards are very spread out across the hospital site, single storey and joined up by covered walk-ways. The buildings are fairly clean, cool and sizeable, but even so the accommodation can feel quite cramped due to the large numbers (50 patients in a ward). There is no Mental Health Act here currently (although there is a long-awaited bill currently going through parliament), so when patients are admitted against their will, it is done with the slightly tenuous agreement of family members as proxy consent. There is a real problem with people bringing members of their family to be admitted... and then leaving no forwarding address or contactable phone number, so even when the patients are well enough to be discharged, there is nowhere else for them to go and therefore they remain at the hospital.
Outpatients' corridor

There are some patients in the “Chronic wards”, who have been here for some forty years and they tend to have employment around the hospital site. There is an Occupational Therapy department, but it is mostly staffed by visiting volunteers at the moment, and the in-patients sometimes don’t always have much to do during the day. Having said that, lots of gardening and farming goes on all over the hospital site, courtesy of the patients.

Despite these difficulties, all the in-patient nurses that I have met have been professional, warm and compassionate. And I was pleased to hear that a retired nurse lecturer, Michael Brenan, is coming over to Pantang with Challenges Worldwide from Scotland in a couple of weeks specifically to work with the in-patient nurses and help them with their professional development. I noticed that a lot of their time is spent completing progress reports in the notes, and less time doing one to one therapeutic work with the patients. There is a very medical model here, with a lot of emphasis on medication and less on psychosocial interventions. I also got the impression that the nurses don’t feel particularly empowered to be autonomous, but clearly they are a huge untapped resource for working more actively with the patients.

Inpatient waiting room, Pantang Hospital
I went to Kokobrite beach this weekend, a beautiful stretch of white sand and palm trees about 30 km west of Accra. I took a “trotro” which are basically shared minibus-taxis that operate all over the country; it is a good way of feeling part of Ghanaian everyday life. It took me about 4 hours to get there though, mostly due to the choking gridlock that is Accra traffic every day, particularly on a Friday afternoon when everybody is trying to leave the city.

The government are working hard to improve the standard of roads, and there are a number of motorways under construction that will relieve the situation somewhat, but that still won’t allow for the constantly expanding population in Accra, of people moving in from rural areas looking for work. When I feel myself becoming exasperated with waiting, in all sort of situations, I have to remind myself... “African time...remember, we are running on African time”.

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About this blog

Susie Easton

Hello, my name is Susie Easton and I am an ST6 on the UCL/Royal Free Hospital General Adult Psychiatry Rotation in North London. I have just got my CCT and when I return from Ghana, I will be moving home to Glasgow to take up my first consultant post.

When I saw the Ghana post advertised, I thought that it looked interesting, a bit scarey and an opportunity for a professional and personal adventure.

This personal blog reflects Dr Easton's own views, and not neccessarily the organisations that she is working with. However Dr Easton is indebted to the partnership between South West London and St Georges mental health Trust, the charity Challenges Worldwide and the Royal College of Psychiatrists for providing an opportunity to take part in this excellent project. She is also very grateful to Dr Peter Hughes for his regular and invaluable clinial electronic supervision, Challenges Worldwide for their excellent logistical support, and Dr Anna Dzadney the Medical Director at Pantang hospital for making her feel so welcome. And last but not least, she is indebted to the Ghanaian Medical Assistants with whom she works, for helping her learn about how mental illness in West Africa.