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.”

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When bloopers aren’t that funny…

This is a follow on piece from the ‘Bloopers’ topic of the other night. One of the bloopers turned sour in a big way, so I thought I should complete the picture. I guess it shouldn’t be a shock that bloopers in healthcare aren’t too funny, mostly. Some are interesting, some awful, and a few hilarious; that’s about how it works out, it seems.

You know that guy I was telling you about, the one with shoulder bursitis? The one whose wife and daughter gave him too much ibuprofen and paracetamol unintentionally, dosing him every 4 hours on the hour for several days due to his excruciating pain without observing the 24 hour maximum doses because they weren’t told about it by their doctor? And obviously they weren’t told about the maximum doses by pharmacy staff either if they bought the medication in a pharmacy, or maybe they bought it from the supermarket; this is my strong argument that these “simple” pain killers not be available from the supermarket. I guess the family never read the packet either, although English as a second language was a factor here for the wife, but not the daughter. This is the patient who was brought into ED after he started coughing up blood as a side effect of ibuprofen which irritates the stomach lining. You’ll remember that the family who wouldn’t give him the stronger pain killer Endone in case he got constipated, but had given him toxic doses of weaker pain killers. The patient who is an example of people being given incomplete advice about how to take their medications, and blindly following that advice without taking any initiative themselves.

Well, he died.

I saw him Saturday, he died early Monday morning. I was shocked when I found out!! I knew what they’d done was bad, and that he was going to suffer the consequences, but I never expected him to die! Not that fast, certainly. I planned on looking up which ward he was in in Monday morning so that I could handover the story to the ward pharmacist, but then it said: DECEASED. I had to read it twice. I thought I’d picked the wrong patient. But no, deceased, 0600 hours, 16-4-2018.

Wow!

So I looked into it. And right there as the cause of death: acute on chronic renal failure precipitated by NSAID use. That’s non-steroidal anti-inflammatory drugs: ibuprofen (Nurofen), diclofenac (Voltaren) etc. Acute on chronic means he had a degree of chronic permanent kidney failure that couldn’t be reversed, not unexpected at 77 yo, but it was made acutely much worse by something, in this case medication.

There are a few things you can do to help reverse acute kidney failure: give IV fluids to flush toxins out, stop all medications that are toxic to the kidneys, manage blood pressure with medication and fluid so that the kidneys have optimal perfusion, but at the end of the day there’s only so much that can be done without the patient going to the intensive care unit and being put on dialysis. Once the kidneys go off, fluid accumulates in the body. This patient already had heart failure which causes fluid to gather around the heart and lungs, and the kidneys failing to clear fluid adds additional pressure on the heart. This was listed as the secondary cause of death: heart failure. In fact 4 causes of death were described in more detail than the overall cause as I’ve put it above, acute on chronic kidney failure precipitated by NSAIDs: kidney failure, heart failure, NSAIDS and age. Once the snowball got kicked off it gathered momentum from pretty much every other medical condition that the patient already had, unsurprising since the whole body is in a delicate balance. But if that trigger hadn’t been there…

In this case because of his age and many other medical conditions, the family did the sensible thing and let things be as they would be; and in this case death is what would be. It’s a shame that kind of common sense thinking hadn’t prevailed any earlier in the case. I feel like this death could be listed as preventable.

If a patient asks me generally whether ibuprofen is good for them, there are several medical conditions I’d want to be sure the patient didn’t have before recommending it: asthma, stomach problems like previous ulcers or gastritis and even reflux, heart failure and kidney failure. So the ibuprofen probably shouldn’t have been started in the first place; a steroidal anti-inflammatory like prednisolone would have been more appropriate. Although sometimes we say cautiously, take it but for no more than x days. Of course we then also tell the patient the maximum dose and how best to take it. In this case I’m pretty sure if you had asked the patient’s cardiologist or nephrologist before hand whether this man should have been given a NSAID they would NEVER have signed off on it.

Then maybe he’d still be here, a bit fuzzy headed or nauseous on Endone, taking paracetamol less regularly than actually happened, and blood sugars high from prednisolone, but alive, his bursitis improving and his life going on at home.

RIP.

I’m sorry the system let you down.

Bloopers

Sometimes you wonder what is going on in the world. A few things at work today made me shake my head.

[Edit: And I’m not exempt from bloopers, far from it. In photography as much as anywhere, as you can see!

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An ED doctor called a renal physician, a specialist, asking advice about treating an immune compromised patient with antivirals. This was a perfectly reasonable request because the patient presented with severe diarrhoea which could be caused  by the cytomegalovirus (CMV) and to quote Australia’s Therapeutic Guidelines, the antiviral she wanted, ganciclovir, “is the cornerstone of therapy”. The specialist doesn’t sound like he really knew what he was talking about, or hadn’t come across the drug much before. That’s still no excuse for him to say, “just give her Tazocin, it covers just about anything”!! Tazocin is a broad-spectrum antibiotic that yes, does cover just about anything…bacteria-wise. It most certainly never has and never will treat viruses however, and if doctors are saying antibiotics treat viruses, how on earth can we expect our patients to be informed?? That was some poor advice!

Nick something-opoulos (name disguised for privacy not racism) keeps his meds in two Decor containers, one for the morning and one for the night. I was getting quite confused because it seemed that his medications were prescribed at weird and something plain wrong times…cholesterol tablet and warfarin being taken in the morning, anti-depressant and fluid tablets being taken at night, and others. I was about to go in there and have something to say, but lucky I asked a question first and found out that whoever went through the meds before me had inadvertently switched the lids. Obviously they didn’t realise how important it is to the patient that they are organised the correct way. Or how confusing and possibly dangerous it could be to have the meds prescribed at the wrong time if a health professional, like me, thought they were usually given at the wrong time and went with it, no questions asked. Luckily its my job to think about these things and we got it sorted. What could have been the consequences? Diuretics, frusemide in particular, are always given first thing in the morning so that the diuresis (fancy name for peeing out the excess fluid!) happens during the day, most particularly during waking hours. Diuresis with frusemide can be hard and past, patients often need to pass urine several times with urgency after taking their medication. Often patients won’t leave the house after taking it, or only if they go to familiar places where location of toilets are known, or they’ll skip it if they have to go out. It can be a significant nuisance. The aim of giving frusemide in the morning is to prevent patients needing to get up hurriedly and repeatedly to the toilet at night time which presents a falls risk, so its very rare to see patients take it at night; the first red flag. The second red flag was desvenlafaxine or Pristiq, an antidepressant, apparently being taken at night. It doesn’t have to be given in the morning but it is an energising medication that can cause insomnia so usually patients start taking it in the morning when its first prescribed, and maybe change it up of their own accord if it works for them to take it differently, but usually it stays as first prescribed. Next up is simvastatin, an anti-cholesterol medication, which must be given at night to work. Simple as that. That’s when cholesterol is manufactured from fats and being the relatively weakest drug in its class, it just must be given then so it can interrupt that process. Some others are stronger and can be taken any time. Then the last but no means least red flag, warfarin in the morning. It doesn’t have to be given at any specific time of day to be effective, but for practical purposes its always given at night. This way you can have your INR blood test taken in the morning, and there’s time for you to be contacted before your dose in case it needs to be increased or decreased. I have never seen a patient take it in the morning. So a whole lot of confusion made a whole lot simpler by switching lids on two containers!

But this was NOT the most confusing thing about this patient. This patient has bursitis of the shoulder and has been in intense pain for 2 weeks!! They’ve been seeing doctors and gradually getting a CT scan, then an xray, now awaiting MRI and has had a cortisone injection over that time. But the cortisone is slow onset and long acting so it hasn’t kicked in. They were told to take paracetamol (Panadol) and ibuprofen (Nurofen) every 4 hours, good advice, but not told to limit paracetamol to 8 tablets per 24 hours, or to limit ibuprofen to the same. This was a massive oversight!! Yeah, sure, it “only” Panadol, and “only” Nurofen but this is exactly how accidental paracetamol poisoning happens. As it turns out this is also how gastritis develops with the patient coughing pink-tinged mucous suggesting stomach irritation and low grade bleeding, VERY bad for a patient on warfarin, a blood thinner; this could get out of hand!! And he’s suffering now not only from bursitis pain, but gastric discomfort and bloating!! Great! Good healthcare. But wait, there’s more!! As I was walking out, the daughter tells me they were also prescribed oxycodone (Endone), a morphine derivative on Tuesday. This is great news, so how has he been going with that? Oh we never gave it to him. Um, why? Excruciating pain, 2 weeks worth, needing paracetamol/ibuprofen every 4 hours?? “Oh we thought it might be constipating”…

…Wait. Let me get this straight. You’ve been telling me how terrible its been watching your father in such bad pain needing pain meds so often…and you withheld medical treatment for 5 days because it might cause constipation;?? That might not even happen!! Excuse me for being incredulous!! Bar one or two, every single treatment for constipation is found on a shelf in your local pharmacy. Most of those are found in your supermarket!! You might never need them, but do have access to them 24 hours a day anywhere across Melbourne. So just give the drug! I think I communicated this point adequately. The daughter then back tracked and said she was worried about addiction!! Seriously, you haven’t given a single dose, and you’re worried about dependence which takes weeks or months to develop, if it does at all while you watch your father writhe!!! It was all I could do to not strangle her!! So because you never gave the drug, he ended up first with a cortisone injection (usually last resort) probably because the doctor thought you’d tried and failed with Endone which you hadn’t, and now he’s being hospitalised because he’s in too much pain, because you didn’t give the prescribed medication!! Constipation, dependence, these are issues that we can work through as we go along. Failing to give appropriate medication, withholding medical treatment; health professionals have been de-registered for these crimes. Yet people in their own homes can get away with it any old day!! What a scandal! If this were a nursing home or hospital it would be labelled “elder abuse” and there would be an investigation and heads would roll!

I shake my head!

Footy season

It’s the start of the footy season.

Did you know that, or care if you did?

Melbourne overall is supposed to be pretty footy mad, and I’m sure it is based on the shenanigans I saw in my work suburb of Richmond over the footy finals last year, but I’m fairly laid back about it. We’ve never had a telly which is probably the major reason why I’ve never followed the footy that much, but if we’re ever on holidays during the footy season I do get pretty enthusiastic watching the play and exclaiming and yelling and carrying on! Who me? Yes me! But following it by newspaper just doesn’t interest me. I’ve also only ever been to 2 games, neither involving my club so…I guess that hasn’t piqued my interest. Theoretically I barrack for Richmond footy club, ironic given I now work there, mostly cos that’s who my Dad barracks for but as soon as people start talking to me about players or games or stats I get lost…except Dustin Martin, I know Dustin Martin. So how about my Dad barracking for Richmond without a telly? The Saturday afternoon clean out of the work van!! The radio would go on, the Coke cans and pie wrappers would actually get removed from the passenger seat foot well, and all the paraphernalia of being an electrician (clippings of conduits, cable ties, old light globes, fuses and things that I’ve forgotten the names of) get methodically cleaned out and the van sorted out for the week ahead. Or a trip to the tip. Or cutting firewood, or taking other trips, or something. Anything, from memory.

So, footy season…why do I now care? Apart from catching a couple of good games over the Easter break when we stayed down at Fairhaven, I work Saturdays in the emergency department. Turns out, we (I mean the hospital I work for) have the contract for the AFL among other sports contracts like the Australian Open so we get injured (and famous!) players coming through our doors, as well as all kinds of junior league and general patients. We’re the only private ED in the city so people wanting fast turnaround, quick (often same day) access to orthopaedics or plastics, private facilities and considerate treatment of celebrities often come to us. Of course there’s still patient confidentiality procedures in place so I won’t be discussing patients by name…and anyway no AFL players came in today to my knowledge, at least not between 10am and 2pm. Who knows after that?

So what did I see today? At least 4 patients lead through the department still in their playing jerseys with various signs of injury: limping, guarding of limbs, blood, pain.

A young 19yo male playing footy this morning went for a mark and the footy hit his ring finger at the tip resulting in a compound (bone through the skin) fracture of his finger…think blood, broken skin, broken bone, and just to top it off, the nurse swore she could see the tendon!! Ick! And when I saw him, he and his mum thought they were being discharged home…sorry, no, this is gonna need surgery!

A young girl maybe 16yo-ish came in from women’s AFL, not the major league but an amateur game with a dislocated shoulder. I actually felt worse for her than the last one because she has to be awake while they sort that out, although on reflection they wouldn’t knock out a patient to fix their finger, just a regional nerve block, probably in the wrist. She still had the green penthrane (inhaled anaesthetic) whistle from the ambulance and after the first attempt to enlocate the shoulder and an enormous blood-curdling scream that shook the foundations, they gave it back for her to suck on in between huge sobs which turned into a panic attack so they switched to nitrous oxide (laughing gas) to both treat the pain and anxiety, and eventually got the shoulder back in! I did not envy her at all! Not pretty.

I didn’t see this guy, but apparently a 57yo male umpire got tackled from behind during a junior game, huge question as to why that even happened, and is now feeling pain pretty much all over his whole body which got unbearable at home so he came into ED. I don’t know what they found in the end, but I’m sure most of the problem was a 57yo rather than a 22yo guy hitting the deck like a sack of potatoes. They don’t bounce back like they used to!

There was another jersey but I never caught up with that one. So instead, another trauma. This one was very unfortunate; I guess all traumas are but when your pet attacks you, its unfortunate. This 21yo guy’s pet is a lovely house cat. His buddy came over to visit and without his knowledge brought his dog. As soon as the dog stepped into the house it went for the cat, of course, so the guy went to pick up the cat but it was freaked out and attacked him…properly! Think slash to the throat, slash to the forearm and wrist, slash under the nose, slash on the chin, and the crowning glory, not just a slash to the lip but a chunk taken right out!! Ouch! Several stitches required, and being a private hospital, and being that the injury is to the face, usually we get a plastics specialist to review the patient at least, if not get them to do the stitches themselves, for a better aesthetic outcome!! Does that sound private hospital-ish?

Point Cook

Friday 16th March, 2018

This one is for a patient from ED tonight who I had a great chat with about photography. No I wasn’t neglecting my work, there weren’t that many other patients to see at that point, and it’s my hobby…always happy to chat about it!

I learnt a lot! About camera clubs at a local, state, national and international level including one that I might go along to locally, we talked about his 3 dark rooms, I heard about UV and infrared photography, and we talked camera models, good lenses for bird photography…and we could have gone on!! But eventually work has to come to the fore.

Anyway, since I shared my blog but haven’t put up a lot of my photos later, I guess I better. These are some shots that I liked from an outing with Birdlife Australia, Melbourne branch to Point Cook on Wednesday. A great walk, perfect bushwalking weather, nice company and a few stunning and semi-co-operative birds! It all makes for a great day out. The day was a bit misty/smoggy so as I cropped all the photos they became a bit murky; apologies!

Brown Falcon

Brown Falcon, better not shooting into the light! 

I got a whole series of shots of this gorgeous creature because you never know how close you’ll be able to get, but this was a youngish bird so we got very close in the end, slowly step by step. So the blurry shot isn’t really excusable, but unfortunately these days I have a degree of hand shaking that is bugging me – I really need to learn to wind up my shutter speed beyond what I’ve done in the past. I have cropped this shot.

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Brown Falcon, same bird but shot into the glary sky

The conditions of the day make a huge difference as far as the photos you can achieve.

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The glare of the sky adds so much light into the camera that it can be hard to make out detail of the subject when you shoot into the light and it is backlit; this is where being able to use your settings well really comes into play…or you just accept that you are operating in impossible conditions…but what fun would that be??

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A Crested Tern on the wing

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Love Terns, they are so acrobatic in the air and a delight to photograph!

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Now THIS is a series I’m super proud of!! Just saying…a little stoush

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Now THAT’S the type of shot I want to be taking!

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Whistling Kite, not a great shot but the best I got

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Perfect! Do you know how close I had to get to this Superb Fairywren for this shot? Actually I had to wait for it to get this close to me. Time and patience pays off! About 2 metres away

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This scrappy looking guy is a male Superb Fairywren in eclipse, halfway moulting between immature and full male adult plumage in the non breeding season – this means he’s less than 5 years old

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I was sitting at lunch and all the birds took off in a big Kuffluffle behind me! It’s a tell tale sign of a bird of prey flying over; there’s a consensus amongst all the birds that this is a bad thing. 4 magpies suddenly went into attack mode and I discovered exactly where the bird of prey was! Not in focus but a nice action shot, I didn’t have much time to get off a shot

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Again, poor focus but I’m proud of this shot because I was the only one in a group of 20 that got a shot, and so I contributed a Brown Goshawk to the day’s count – I’m happy with that!!

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Spot the Little Wattlebird!

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Not perfect but a Black Kite right above my head?? Wow!

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And 2 Black Kites up there?? Perfection!

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This was my other moment of contribution – an immature Australasian Gannet, in the bay, out of the colony, away from Geelong, all on its own! I picked it out, someone else labelled it, lots of excitement all around! Love the spotty plumage – the adult is very monochrome

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Silver gulls (usually called Seagulls), Crested Terns, Chestnut Teal ducks, Little Pied Cormorant – these are all roosting in shallow water in the bay

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Little Pied Cormorants and Pied Cormorants – you can see the size difference clearly

Well, there’s some recent photos. I was overall a bit disappointed with the quality which was partly due to the weather with the glare and the smog, partly due to the settings being poorly managed and somewhat to do with this shake. Maybe I need to make a tripod part of my regular outfit for camera stability, maybe I need to go back to photography school to refresh the basics of which settings to use when, and let’s see what the doctor says about my tremor!

Enjoy!!

Goods and chattels

I’ve done this before. But since it’s a recurring theme with me, I guess it can be a recurring theme here too. It never ceases to amaze me the STUFF that goes along with medicating oneself.

The medications to start with, the prescriptions and repeats, script reminders when the repeats are running low, the safety net form to keep track off the scripts til I hopefully reach the concession limit, the receipts…well they aren’t mine but they remind me of what of mine I’ve spent…the script wallet.

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And then there’s the waste. I’m a believer in recycling and the whole reduce, reuse, recycle ethos but what do you do with this?? And this is every TWO weeks!!

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I bin or recycle, but there’s no way to reduce or reuse this lot!! Oh well, I guess that’s a bigger fight for another day.

4 years

6th March, 2018

Well I had other ideas for today’s blog, but Facebook reminded me that today 4 years ago I was recovering at home, supervised by my hubby working from home, after a VERY long afternoon/night in the emergency department having finally come to the crunch point of my nervous breakdown.

It was the first day of many days off work: 6th March 2014 to 22nd July 2015.

It felt long!

It felt like it would never to over, that life would just trickle by forever. Me at home, on my own, barely able to fill the hours of the day, just dragging along until the next…what? Hour, day, week, year?

After 18 years of full time school; 4 years of full time study plus part time work; an intern year of full time work and study; and 4 years working full time (apart from a period of 9 day fortnights during 2013 for health/stress reasons, and a brave if futile attempt to get back to work and save my job by dragging myself 2 days a week to work in the outpatient dispensary at the Alfred in the month before my contract expired late 2014) it was a shock!

I didn’t know what to do with myself physically, let alone mentally. So came a long list of attempted hobbies to try to fill up my time, more or less successfully. 4 years on, some have stuck, some haven’t, but it’s a different problem now: finding time for those hobbies! Time for bird watching, for photography, for blogging, and my re-discovered love of gardening. I’m back at work, currently 4 to 5 days a week! Who would have ever thought?! And it’s cramping my style! How’s that for ironic? For months, years in fact I’m dying to get back to work, really back to working full time or close to it, and 5 minutes later I’m missing my me time!!

It could be worse. If anyone can say that it’s me. I was worse, I’ve been worse; so I really know that it could be worse. I do. But it’s the perspective you have at the time that frames how you see things. And my perspective now is mental wellness and relatively good physical health, so the smaller things weigh more, like doing my hobbies! It’s not a bad place to be, hey? Four years on.