Non-compliant

There’s a funny thing that you see over and over and over in healthcare: people who ignore their doctor’s advice, be it their GP or specialist, then come to the emergency department for help when they reach crisis. I guess there’s something human in us all that makes us think we’re above taking advice, even when the person giving advice has a level of expertise that we don’t. But when a complaining patient is only in ED through their own actions it can be hard to feel terrible for them. They still get the appropriate treatment, don’t get me wrong there, but when you’re done and dusted dealing with them you might share a roll of the eyes with their nurse or doctor over their behaviour.

You didn’t pay any attention to your doctor before when you were told how best to manage your condition, so why would you listen to us now? More to the point, are you going to listen now? Or maybe you will listen right now because you’ve scared yourself with how sick you’ve gotten, but how about next week, or next month? Will it be back to old habits? You got yourself into this, and now you think we would help you, because…? Of course, ethically we have to help you, even if we think you’re a dodo who has made their own bed and should possibly have to lie in it, but we spend a lot of time shaking our heads. There are a lot of sincerely needy patients: fractures, cancer patients, appendicitis, infections, many patients who have illnesses out of their own control. And when those patient’s beds are full of patients who could have avoided being there…well it grates on a few nerves is all. But we’re all only human, so we try to understand you, and anyway we’re health professionals so it’s our job to give you our best assistance regardless of our personal opinion. A professor at uni once gave this quotable quote:

“professionalism is a cloak for our personal problems”.

Compliance is the word of choice adopted by health professionals to discuss, at least in pharmacy terms, how well a patient manages to comply with the regimen of medications given to them. Do they take the medications prescribed, do they take them at the time/s prescribed, with or without food as prescribed, separate in time to other medications as prescribed, for the duration prescribed and so on? If so then they are described as compliant, if not then they are said to be non-compliant. There’s a bit of political correctness around which word you use because of the effect it might have on the patient if you “label” them. Adherence is another option, concurrence is almost never used and there’s one that I can’t think of that’s been ruled out. It applies in medicine terms as well as in other fields.

So a patient arrives at the emergency department. The presenting problem, that one main issue that has caused them to come to us right now? They have severe pain, 8/10 on the usual pain scale. And why? Well they have a chronic pain condition, whatever that is, and we know that they can relapse from time to time, but actually the reason for this relapse is that the patient stopped their pain meds. Okay, so you’ve come to the  emergency department for help: what exactly do you think we’re doing to do, other than restart your pain meds? Surely you could have worked that one out. I get that pain meds have a lot of side effects that can be hard to deal with. But wouldn’t it have been better to sit down with a doctor and work out a management plan instead of just stopping something yourself? Now, instead, you’re in worse shape than ever and we have to pour MORE pain meds into you just to get you back to where you were, not to mention the time that will take, time that you’re writhing in agony. It doesn’t make sense to me. If anyone knows how tedious and frustrating the side effects of medications are, I do. Seriously. I put on 20kg, was sedated for 4 years, couldn’t work for 2 and I sweat all. the. time!! And that’s just 1/3 of the list. But you don’t just stop your meds because you don’t like them. You go back to your doctor, talk about the problems, work with them to adjust your meds and try again. That’s my experience. And when people come to us having not been bothered to put in that work and short cutting the process, then screaming that they’re in pain which is the obvious outcome, it just doesn’t make sense. They have a lifelong pain problem, surely taking the effort of one doctor’s appointment isn’t too big an investment to make? This especially bugs me for people on insurance and worker’s compensation because those establishments will do anything to help get people back on their feet (and back to work, of course) including paying for doctor’s visits, therapy like physiotherapy, and medications. You just have to be willing to work with them. People do “get over” their condition and the ramifications of it, I get that; so do I! But you’re kind of stuck with it so sometimes you have to dig in and just work through it. Going off course just isn’t going to make it any better.

Another common presentation is asthma attack. That’s not so shocking, except when its because you didn’t bother to take your asthma preventer inhaler for the last 3 months; you “thought you didn’t need it”. What are you thinking now? Are you going to go home and take it now? Did you ever think that maybe you never had an asthma attack BECAUSE you were taking your asthma preventer, rather than that you didn’t have asthma and didn’t need it? Did you ask your GP to review your asthma and maybe check your respiratory function tests again before making changes? No, you thought you knew better. And if you start giving me that big pharma conspiracy rubbish about how GPs diagnose people with asthma and prescribe them asthma preventers to get kickbacks from some drug company, I’ll scream. They did it to save your life; asthma kills! Have you heard of the tragic thunderstorm asthma event of 2011? And that’s just what people hear about. People die all the time of asthma. It’s not just some kids disease, or a disease that doesn’t really matter, or one that can be treated every time it flares up if its been under poor control. That cough you get walking up the stairs? That’s your asthma. That tightness in your chest on a cold morning? That’s your asthma. You don’t have to have an audible wheeze to have symptoms of asthma. Take your preventer, get reviewed regularly by a doctor and you can control your disease. But take it seriously please. And FYI, when the label says take TWICE daily, that means two times, as in morning and night, not once a day. If you use your preventer once a day, it will only be in effect for 12 hours; the other half you are on your own. And if you use your Ventolin/Asmol inhaler more than twice/three times each week? Your asthma is NOT under control!

One of the worst examples of non-compliance is patients saying pure and simply “I didn’t take them”, especially antibiotics. Why did you bother to see a doctor if you then went ahead and ignored their advice? It’s kind of rude. And self-jeopardising. And for those patients who DO go ahead and take the antibiotics, did you know that almost no one actually takes their antibiotics as prescribed? If its prescribed three times a day they take less. If its prescribed for 7 days they take less. And YET, every time antibiotics are dispensed, patients are told how to take their antibiotics, and for how long, and to complete the course. It really is just up to them to take them. There are apps (e.g. NPS Medicine Wise) where you can enter your dose, and duration of antibiotic, and the app will send you a reminder each time you are due for a dose. You can use the alarm clock on your phone to remind you when your dose are due. You can have your pharmacy add the antibiotics to your Webster pack, or you can add them to your dosette box. Really there are a lot of different strategies you can use. But know that when you come into hospital, your pharmacist, and probably your doctor, and maybe the triage nurse will note the date you were prescribed your antibiotics, COUNT how many antibiotics you have left and do the math; it’s what we went to uni for! And non-compliant will be written on your chart. Just take them. Why go from a slight upper respiratory tract infection or small wound, to a full blown lower chest infection and disgusting weeping sore when you could have prevented it? Sometimes conditions progress anyway, but do your part at least. Plus incompletely taking a course of antibiotics, not killing off the bug fully, leads to it learning resistance to that antibiotic so that next time you take that antibiotic it won’t work as well as it should. If you spread that bug that has resistance to someone else, you’re spreading resistance. You really don’t want to be that person. Take them, take them as prescribed, and take all of your antibiotics.

Or there’s that person who hasn’t been bothering to take their cholesterol lowering tablet and is admitted with a myocardial infarction (heart attack) and has to have 3 main vessels in their heart unclogged! All because they thought their cholesterol level was “fine” and they didn’t need it. Did you ask your doctor about that before you committed to that course of action, triple bypass guy?

Or hasn’t been bothering with their blood pressure medication and their systolic blood pressure at the bedside is over 190 when it should be at least under 140 and ideally around 120. They insist that they have white coat hypertension which is where patient’s get nervous before their blood pressure is taken, or around doctors, and it causes their blood pressure to rise. Except it doesn’t ever cause it to rise that much, in-denial lady. Take your blood pressure tablets unless your blood pressure falls below 120, and even then keep taking it unless your doctor advises you not to. Yes your own blood pressure machine might tell you ONCE A DAY that your blood pressure is okay when you’re sitting around relaxed at home. But why did your doctor diagnose you and prescribe you tablets in the first place? So many people are so reluctant to take blood pressure tablets and I don’t know why. In most cases its one tablet once a day and the side effects are usually mild, it’s really not a big deal. And again, its not a big pharma conspiracy to get you to take tablets, it’s a lifesaving prevention strategy to stop you having a heart attack, killing your kidneys or bleeding your brain out…why not take your tablet??

Just take it, or talk to your doctor. Those are the main concepts here. Confusing?

Edit: I’m not perfect. No one is perfectly compliant with their medications. I know that. I miss doses of my tablets, in fact I missed last night’s meds cos I broke my routine. But one thing I don’t do is miss them on purpose. All I’m asking if for people to try to carry out their doctor’s directions, for their own good. I read a quote yesterday,

“No one is perfect. But if we aim for perfect, we might reach wonderful.”

Published

Recently I took an art course, more on that later, and so I had to head into my local art shop for some supplies. While I was there I noticed a flyer advertising an upcoming local art exhibition called ‘When The Black Dog Bites’. This immediately grabbed my attention because of the reference, intentional or otherwise, to The Black Dog Institute, a mental health foundation set up by a guy with lived experience with mental illness who is now raising money and awareness for mental health around the country. They have a great website and a great book about living with the black dog which is what he calls depression; check them out at http://www.blackdoginstitute.org.au, there’s a ton of interesting stuff there including self help resources and professional training.

20181104_214245-2

Because of my journey with mental illness this exhibition appealed to me, but at this stage I was no artist!! But I happened to notice on the flyer that they also accepted written pieces and that’s right up my alley, as you know. So I got to and wrote a little something about when the black dog bites, which to me is about when depression hits. The flyer suggested writing something about mental illness, and hinted at a focus on hope and I tried to stick with that approach, because isn’t that the only way to get through this? Focusing on hope?

I entered it in the exhibition, and they hung it on the wall, and I got that cheesy photo pointing at my published piece and smiling, and now I’ll never see it again because I couldn’t pick it up on the last day and the curator doesn’t answer her emails!! Oh well. At least I can say I’ve been published, and not just self-published here. The general public got to see my writing and that’s pretty cool. I’ll never know if they liked it, but actually its more important to me that I wrote it, and got it into the exhibition, than what others thought of it. It got some of my thought out of my head in solid form and that’s always good, otherwise my head would explode!

Resized_20181021_151350_2496.jpeg

I went to the exhibition with hubby halfway through the opening and it was fascinating to see each exhibitor’s different interpretation and own experience of mental illness. I associate the black dog with depression, probably because that is what has affected me most, but other artists painted or drew or wrote or sculpted or crafted about schizophrenia, bipolar, depression, anxiety, PTSD, autism and others; it was a real medley. A couple of art pieces were truly disturbing!! I didn’t need to see those. But there were some really thoughtful and insightful pieces there.

Overall, I think it made me realise that although I like the idea of such an exhibition, I don’t like bathing in a room of mental illness art emerging from the rawness of people’s souls! It’s too much, too real, too full on. It’s a room full of triggers waiting to go off and snap your fingers and sensitive parts of your brain like mouse traps! I wouldn’t go again. But hey, now I know that and I didn’t before. It’s too much like sticking your tongue in an electric socket after having being electrocuted.

So here’s what I think about when the black dog bites. I’d be interested to hear what you think. Enjoy!

– – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – –

When the Black Dog bites

When the Black Dog bites, it’s okay.

It’s not okay that it bites, but it’s okay. You will be okay.

It’s okay to stop. It’s okay to retreat from life. It’s okay to let go of commitments, at least for a little while. It’s okay to stop.

It’s okay to eat what you want. It’s okay to drink, but only a little. It’s okay to wear your pyjamas all day, and stay in bed, and get nothing done. It’s okay, for a while.

Do what you need to do to make you feel okay. Touch a smooth stone or soft velvet, get a massage or new hairdo, watch people laughing on TV, snuggle in your blankets and sink into your pillow, indulge in your favourite treat, take a bath. Do whatever makes you happy and makes you feel okay.

It’s okay to cry. It’s okay to scream. It’s okay to hurt, for now. It’s okay, it won’t last forever. It’s okay.

Talk. It’s okay to talk. Talk to someone, anyone. Your best friend, a work mate, your mother, a help line, your diary, a recorder; just talk. It’s okay to talk. They won’t run away, and if they do, persist and start again with someone else who will show you its okay. You’ll be okay if they run away. There is someone out there who will hear you and show you that its okay to talk. It’s okay to be heard. It’s okay to talk.

It’s okay to see a doctor. It’s okay to have a diagnosis. It’s okay to take medications. It’s okay to see a psychologist, a psychiatrist, a counsellor, a therapist. It’s okay to get help. It’s absolutely, and necessarily okay.

It’s okay to ask for help. It’s okay to accept help. And if the help isn’t helpful, it’s okay to reject help. You know best what help it is that you need, so ask for that help and accept only that help. It’s okay to be choosy and try, try again to ask for help. Just don’t reject all the help. Once you’ve found the help that you need, accepting that help is okay.

When the Black Dog bites, hygiene becomes hard. Really hard. So I’m here to tell you, not showering for a week is okay. Not showering for however long is okay. Not brushing your teeth, or combing your hair, or doing your makeup today is okay, but use some deodorant; you’re still human. People won’t like it, and eventually you’ll have to change, but right now, it’s okay. When the Black Dog bites, it’s okay.

In fact, nearly whatever you do when the Black Dog bites is okay, whatever you need to do is okay. Focus on you, on surviving this bite, on being okay for now. You know it will pass and you’ll be okay again, for real. In the meantime, it sucks. It really sucks. So, do what you need to do to be okay for now.

And someday soon, it will be okay.