Minor issues

[Started Tuesday 27th October, 2015; continued Wednesday, Thursday, Friday, and finally got to the point, sort of, on Saturday!!]

SOo I’m over my deadline again! It’s Tuesday, not Monday. And it’s Tuesday night! Oh dear.

I’ve been trying, but the other two pieces that I’ve been trying to get publish ready are just not ready. I need my chief editor, my husband, to review them and he’s away…poor me! Of course I’m joking about poor me, no poor me whatsoever.

But, since I’ve had some minor issues lately, let’s talk minor. I’m not sure who it is that decides what’s minor and major. I’m guessing someone who doesn’t have issues either major or minor, because if it was anyone with any issues, they would no doubt rate their own issues as major a fair bit of the time.

That’s what we’re like, isn’t it? Whatever affects us, feels like the most important thing going on. There’s nothing wrong with that, it’s just how we are. It’s hard to feel for an issue that doesn’t actually affect us, without a great deal of thought and effort, which we don’t always have to spare.

The issues that I’ve been having are medication related. Side effects; well side effect-ish. Sometimes they’re non specific and vague, or even unexpected and the dots don’t get connected.

You know that I’m a pharmacist, and therefore you expect me to know the side effects of medications. I expect that of myself as well, and I do know them; it’s my job. Naturally I can’t know every single one. The aim is that pharmacists know the majority of side effects, definitely the vital ones, and know where to look for the others in our reference books. Our mantra is: until proven otherwise, assume every symptom is a side effect. Umm, did I read that right? Hmm, seems that I may have forgotten that in relation to myself. Oops!

Side effects are ranked as common, uncommon and rare with a special mention for life threatening effects. Common side effects are those that we expect in around or upwards of 10% of patients; uncommon means around 1% occurrence; and rare is 0.1%. Something like that, as a general rule.

When I counsel a patient on a new medication, we talk about all of the common, and some of the uncommon, side effects, and we discuss rare side effects if they are very severe. Must say, I have been surprised at how much of this information I’ve retained despite such a long time off work! I quite expected to have forgotten a lot! But that part of my brain is still alive and kicking, fortunately! Learning it again would take a great deal of time and effort, and I think I’d give up before I began! So I’m glad that all I have to do is remember the path to that information, and it’s all sitting waiting for me.

Side effects don’t occur exactly as the math indicates, obviously; the math just gives us a ball park of what to expect when a patient takes a medication. Some patients never get side effects, some people get a really rough go with lots, some have one or two, and some people can’t even breathe the air of the pharmacy without developing severe side effects. It depends on all kinds of things; genetic, psychological, race, age, number of medications, how you process the medications through your kidney and liver, and more.

I know the side effects of my medications. But the pharmacies I’ve been to don’t know that. Some gave me CMI leaflets, some mentioned a side effect or two; but I’m ashamed to say that most of my pharmacy encounters have involved a pharmacy student or intern or practicing pharmacist handing me my medication and asking, have you got any questions? This is infuriating! How do people know what they don’t know, and therefore how can they ask questions? Pharmacists really need to pull up their socks on this! The responsibility is on the pharmacist to ensure the patient has enough knowledge to safely use the medication, and if I wasn’t a pharmacist myself, this would not have been the case with a single episode of having a script dispensed.

Did you know that 1 in 3 hospital admissions are medication related? That’s a very serious statistic. Imagine how that could be improved by pharmacy staff just taking a little extra care! I know they do care, and I understand that the sheer volume of workload is very oppressive, but surely we can do better.

Some of the side effects I’ve had have been textbook examples, and I actually find this very satisfying! It impresses me when what I’m experiencing is exactly what someone has described in the medical literature. How clever of them, and how observant! Of course when I say I’m impressed, I don’t mean that I like it, or appreciate it. But I think that the person who wrote it down was very intelligent, and perceptive especially for the era that they worked in which was often centuries ago, and the fact that we still find their information relevant however long later is such a testament to them.

So my textbook issues impress, but frustrate me: sweating, hunger, weight gain, sedation, increased blood pressure and cholesterol, suppressed thyroid, heart burn, memory impairment. And the consequences really get me wound up: chafing thighs, red face, jiggly bits, lethargy. Not all minor, of course.

But as an example, I would never have thought sweating was a big deal. So what? Everyone sweats. It’s just natural. Or perspires; if you’re ladylike! You’re exposed to heat, you exert yourself, you sweat. You wear deodorant to prevent smell, you take a towel to the gym, you shower as often as necessary; and that’s the end of the story. There was this one guy at my old job, an orderly, and by the time I walked into work at 8.30am he already had enormous arm pit, neck and back sweat patches going on. I felt very sorry for him, only a young guy! He is really a candidate for botox injections into his sweat glands to block them permanently and give him some dignity! Or aluminium deodorant, much easier and available at your friendly local pharmacy.

And now it’s me. As always the subtleties fascinate while irritating me. I don’t sweat how you’d think: armpits, back, neck line, like you get from exertion. I sweat like a normal person, with the addition of sweating on my face! Nice and visible, up front and prominent! In defence of this sweating I armed myself with a whole host of clinical anti-perspirant products: under arm roll-on, face gel, leg and groin gel, and used them liberally. Under arm: success, leg and groin: success, face: fail!! To be honest I’m not sure that the others do a lot, cos I don’t sweat there anyway…but the one I really need fails! Or just doesn’t work as much as I want it to, I guess! I’m a bit hap hazard with remembering to use it, but at the end of the day if its slightly warm, if the sun shines, if I have a shower, if I wear too tight or too much polyester clothing, if I get stressed or upset or nervous in any way, I sweat from my face!

sweating, cooling

My doctor recently gave me the medical reason: my core temperature has been increased by as much as one degree Celcius by my anti-depressant. It’s to do with the increase of serotonin. It doesn’t happen with all antidepressants; mainly the class that I’m on that also increases noradrenaline. 1 degree isn’t much as far as the outside temperature goes; I doubt you’d notice it. But our body is extremely finely tuned and our core temperature should always sit between 36.5 and 37.5 degrees. If you’ve ever had a fever you’ll know how crook you feel when your temperature is about 38.3 degrees. But that’s where I am all the time! I get hot, prickly, sweaty, slightly nauseated, and irritated at the rolling sweat beads multiple times a day!

My new comfort zone is when the outside weather is below 20 degrees. I’ll be the one in a T shirt deliberately sitting outside just soaking up what its like to not be hot, not be sweating, and just comfortably existing!

Is there a solution? Yes. It involves a maximum of two layers of thin cotton clothing, fans, air conditioners, face gel (might as well keep using it!), tissues, handkerchiefs, anything that will mop a brow, a bicycle to create my own breeze, and suppressing my pride. For every time someone looks at my forehead while talking to me, asks me if I’m okay because I’m sweating, every painful time I’m forced to use my hand to mop my brow because I’ve run out of nicer options, for every time I’m counselling a patient at the bedside with my hands full and sweat is starting to roll down my face! ARGH! I know I’m not the only one, but you can only feel your own problems, can’t you? No one else sweating makes me hot and prickly!

But, this is the only antidepressant that has ever truly worked for me, so I’m sticking with it! Reluctantly, unfortunately, but the show must go on. And if I’m not on this medicine, the show will rapidly cease to go on. This brings up an interesting concept: what side effects are you willing to exist with, in order to get the benefit of your medication?

A lot of people have asked me whether I’ve considered stopping my medication. The answer is distinctly NO!!! Seriously, without knowing anything about my condition, my medication, and the subtleties of mental health, how could you ever ask that? And IF you ask it of anyone, you have to be responsible for the outcome, which may be dire, just like a doctor would be!! I understand that you are asking out of care an concern, I do. But it’s not an option with me.

Some have asked whether I’ve considered natural therapies: well NO, I want medications proven to work. And the ONLY natural therapy with evidence for depression is St John’s Wort which is only recommended in mild to moderate depression, which is not what I have.

So this is life. I sweat, not that big a deal when you consider the grander scheme, but oh so degrading on a day to day basis. A minor, but not so minor problem. Still, it’s not a suppressed immune system, or clots in my legs, or a physical disability. I can live my life, mostly do what I want, and be functional. That’s a pretty good hand to be dealt!

I promise I won’t hate you if you can’t resist looking up when we next talk. I won’t be annoyed at you for noticing. It’s just how I am now, and I’m trying to roll with it. Because in the end it is worth it, you know? I couldn’t live before; now I can live pretty happily. It’s just this one thing, and that other thing, plus the other one that take some dealing with, but it’s okay. It’s worth it!

Safety Net

I hope you don’t think this is me crying poor, because I know how lucky I am in so many respects. In fact, I often use the types of figures below to show my patients how financially lucky we are to be treated in the Australian healthcare system, and not in a user pays system like the United States of America.

We stay in a public hospital and never know anything about the $2000 per day that it costs the Government to enable you in that bed to have access to whatever you might require. You have blood test after blood test, and you don’t pay for it. Your meals come free, and you don’t have to pay the doctor, the nurse, the nurse’s aide, the ward clerk, the person who takes your blood, the physiotherapist, the occupational therapist, the social worker, the pharmacist and so on. You may have to pay a small fee for the podiatrist, and the TV, and your discharge medications when you leave.

When compared to the tens of thousands that Americans or their health insurance providers have to pay it’s nothing at all!

But at the end of the day, poor health does comes at a financial cost. That cost may not be anywhere near what it could be, and might not compare to someone else’s cost, but it’s a cost regardless and this is just my example.

I take 8 different oral medicines, be they tablets or capsules or dissolving tablets. I take all of these every day, and some of them a couple of times a day. I think I do an alright job of keeping up with it all, and I’m a pharmacist. I can tell you that my respect for patients who manage their own medications has sky rocketed this year!

An 80 year old lady tells me off that top of her head that she takes these 6 in the morning (and she names them by name!) and these two in the evening, and she is meant to take this one but she’s getting this side effect and so she talked to her doctor and now she only takes it every second day, and her insulin has just been changed and now it’s 8 units in the morning but if her blood sugar level is over 10 she takes 12 units, and if she has to go out in the morning she doesn’t take her fluid tablet til she gets back etc!

It’s exhausting to listen to, and I always congratulate them because they do an amazing job! With all of my medicine specific education I am still not doing as good a job as that! All the things that patients have said over the years are coming home to roost.

“I can’t tell you off the top of my head, but if I had my list I could tell you. You should be able to find my list in my history; I gave it to them in ED”

At which I inwardly groan, knowing that in 99 cases out of 100 the list will be nowhere to be found and no one will know anything about it, and the patient is now a useless reference, with their knowledge locked firmly in their brain, and no release key to be found. It’s so unfortunate. I recommend every patient to create their own medication list, or I do it for them when they are being discharged home but whoever borrows it first in the hospital seems to put it with the odd socks and off it goes into the ether.

So I’m always thrilled to have an A type personality carer who have neatly run off 10 copies of the medication list; one for every medical professional who asks for it! Of course I’m less thrilled when they start going all A type on me because Mother’s glucosamine is being given once a day instead of twice, and her cholesterol tablet is meant to be night not morning, and when will someone attend to her rash; it’s not itchy or sore but someone needs to do something about it, right now!

“I’m sorry, I just can’t seem to remember. If you tell me the names I’d remember. If I had the box in front of me I could tell you how I fill it, and I’d remember the tablets. If only I had my tablets with me!”

Another inward groan. This patient from home alone with no next of kin to go to the house and collect the box, so again, knowledge locked inside. And no I’m not going to sit beside you firing off common medication brands in the off chance that one will trigger a memory. I have better ways around that.

But I do then find myself unable to give a full list without at least once or ten times referring to my written list or to the dosette box I make up. It’s a hard job!

And that’s just managing the meds themselves. Then there’re the scripts, the doctors appointments, Medicare, PBS, etc.

So these are my figures. At the 12th October 2015 I had officially spent $1,526.13 on my medications. That’s 8 medications, every day, over the course of the calendar year since January 1st. It sure creeps up on you!

Any patient with a Medicare card and no concessions on 8 medications, or less or more depending on the actual cost of each script, this could apply to you.

It also applies if you are on a pension card, but because pension holders have their prescription costs capped at $6.10 (or whatever it is capped to in each calendar year) you are eligible for the safety net when you reach a certain NUMBER of prescriptions, rather than a certain cost. For example once you have had 62 scripts dispensed, then you’re eligible for the safety net.

Every year the government sets an amount of money which if you spend that amount of money on PBS prescriptions, you will be eligible for the safety net. For 2015 the amount of money is $1,453.90. If you spend this amount of money on your scripts between January and December, you are eliglible for the PBS Safety Net.

How do I know if I’m eligible? Simple mathematics, my friends. Which is simple if you go to the same pharmacy every time like a sensible person would, so that said pharmacy had all of your records and could give you the best care. However being young and mobile I have gone to pharmacies far and wide across the country. And now I have to track them all down! I did have some idea of this coming, so the good thing is I had receipts from every script and every pharmacy; now to track them down!

Macleod Pharmacy

Chemist Warehouse Box Hill

My Chemist Box Hill

Surrey Hills Chemmart

Pharmacy 517

Tathra Pharmacy

Chemist Warehouse Shepparton

Nunawading Amcal Pharmacy

Amcal Max Doncaster East

Seeto and Dodd Merimbula Pharmacy

Duh!!

Now I remember why I should always go out of my way to go to the same pharmacy every time!

Instead I chose convenience at the time, and now I’ll have to traipse all over the city, and do some interstate sweet talking to have stuff posted, to get everything together in one place.

Bring on Australia-wide electronic records where every script I have had dispensed is automatically recorded and when I reach the PBS safety net a card is automatically posted to me, and I get a SMS alerting me to my status and card number! Sounds much easier and less time consuming to me.

There are proper forms so that each time you get a script dispensed the safety net stick can be attached, and you gradually build up…but of course that was too logical for me this year as a newbie to the scheme as a patient. Next year I’ll be all over it!

So 1300 words so far, what’s the point of all this?

Well, the safety net does this. Instead of paying some amount of money up to the $37.70 capped price for each prescription that I get dispensed, I will now only pay up to $6.10, the pensioner price!

Can you imagine? The average cost of one of my scripts up til now has been between $15 to $25 usually, with some actually capped at $37.70. So already by living in this lovely nation I’ve been saved a fair bit of cost through this genius Pharmaceutical Benefits Scheme (PBS). And now I’ll be saved a heap more! And if I were already on the pensioner price and reached the safety net?? Zero dollars for the rest of the year for PBS items. I make this disclaimer because even on the safety net, if you are prescribed an item that isn’t covered then of course you still have to pay what anyone else pays.

So this is a major saving to the individual! And I’ve never been so excited about maths, as when I thought to myself that I might be close to the safety net, and found out that I was over!!

Of course now I have to go and line up at Medicare to get a refund for this difference…………………………………………………………………………………yeh.

But it’ll be worth it, won’t it? $6.10 for the rest of the year; I’m getting that tempting sensation to do what all the oldies do and queue down the street to get all of their scripts dispensed on December 31st! Will I, won’t I? We’ll have to wait and see. But the sales junkie inside of me is stirring…