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.”

Revolt

*WARNING (and spoiler alert): contains self-induced vomiting*

12th April, 2017

From one drama to the next! Honestly! Did I learn nothing from yesterday? The whole phone thing? Nothing about being careful and deliberate in my actions?

See, I have this system. Yeah right! A system is useless unless you stick to the system. Which I mostly do, but mostly isn’t really enough when there’s a system involved. You stick to the system, or you don’t.

This system involves my medications. I’ve probably been over this but I have a nice purple medicine box with 4 rows. One row for my morning tablets, one empty row, one row of 3 valproate tablets for each night still in their original foil because they go smooshy when exposed to air, and the final row for the rest of my night tablets. The valproate for the evening doesn’t fit with the other tablets, hence its own row, but the morning single valproate tablet fits it, hence the empty row. I have carefully marked the morning tablets, and the night tablets so that I can’t get confused. Plus there’s the fact that I unwrap one valproate tablet in the morning and three valproate tablets in the evening. The morning row has red and pink capsules of venlafaxine and 3 little white tablets; the evening row has a dark red iron tablet, a little pink cholesterol reducing tablet, and three chunky quetiapine tablets, apart from the lithium that is in both morning and evening. They are different, the morning and the night tablets; clearly distinguishable. They are not the same. If you take the time to notice, which I periodically don’t! Theoretically, I check all the tablets lying in my palm, to make sure every one is present and accounted for before swallowing them down. I have a list written on the back of the box telling me exactly what should and shouldn’t be there, for reference. But I’ve been on this same combination of tablets for well over 6 months now, and I’m very careful when I pack the box, supposed to be anyway, so sometimes I just pop the tablets and scull them down, get it over with!

Like yesterday. Before I knew what I was doing I had opened 3 valproate tablets, shaken out the dark red and pink tablets, noticed subconsciously the big chunky tablets, and sculled the lot! Even though it should have been obvious that I was taking the wrong tablets: wrong compartment, wrong colours, wrong amount. It took about 20 seconds to get that same shot through the gut as I had yesterday when I realised that I’d lost my phone. I knew then, consciously, that I’d really stuffed this one up!! It has happened before, once I think, but seriously! What was I thinking? And here’s the thing, I wasn’t. I was on auto pilot, distracted and that’s how it all blows up in your face. What’s the big deal? Those 3 valproate tablets, plus the 3 quetiapine tablets, they’s the big deal. They are basically my sleeping tablets, and here I’ve taken them 10 o’clock in the morning! They aren’t actually prescribed for sleeping, they are mood stabilisers but this is their major side effect. Any other day I’d just resign myself to going back to bed and sleeping them off, but not today.

Because there’s something else that I haven’t told you. I’ve got a job!!

I was going to save the excitement for my official start date on 29th April, however this happened, and on the first day that I’m going in to do the official orientation and get all of my paperwork sorted! I have a 4 hour shift starting in an hour and I’ve just taken my sleeping pills by accident/carelessness!! You can see the problem here. First impressions and all that, I don’t want to call in sick for my very first shift; I’m determined to be there and on time and get this job off to a good start. I don’t want to have to go home sick part way through the shift because I can’t keep my eyes open. I definitely don’t want anyone to think I’m under the influence, or unfit for work! That would be extremely unfortunate! Not just for this job, but for my career; the pharmacy board frowns heavily on pharmacists using any substance while on duty, oddly enough. So, what to do? I think you can see where we’re going now.

The ONLY way to try to prevent the sleepy pills doing what sleepy pills do is to get them out of my stomach before they are released from my stomach to my intestines, and absorbed into my bloodstream, making their insidious way to my poor brain. The only way to get them out of my stomach is to induce vomiting!! Honestly, I cannot think of a more revolting, horrifying task to have on ones hands than this. I don’t think I have ever made myself vomit before. I recognise now how compelling a disease bulimia is to convince you that this is a way to live. To me it is extremely repugnant. But what are my options here? It took a lot of psyching myself up for it, and a couple of false starts, don’t ask me how, but we got going. Here’s the killer: I ended up throwing up my entire breakfast which I’d had an hour and a half ago, yet there wasn’t a sign of the tablets and orange juice from 10 minutes ago. Here is the cleverness of your stomach. It knows that its job is to break down food into smaller pieces so that your intestines can do their job. But there’s nothing to break down in fluids, so your stomach lets them right past. In that 10 minute period, my stomach had already released all the fluid/orange juice, and the tablets with it, and they were gone. That whole disgusting, humiliating, distressing episode, for nothing!!

What next? Well, its time to go to work. Fingers crossed that I can handle this and get through what I need to get through.

Here’s the odd things about my sleepy pills. When I first started taking them I would be dead to the world within 30 minutes, or less. Honestly, I would take them and immediately get upstairs to bed because within 10 minutes all of the muscles in my legs would be jelly and I couldn’t step up a stair if I was being chased by an axe wielding madman! My arms would be equally useless. A couple of times I got into bed and then needed to go to the toilet. I would bounce off the wall, my bed, the dresser, my bed, the wardrobe, the bedroom door, the bathroom door and back again! I’m sure it looked completely hilarious from my husband’s point of view but I couldn’t even see straight, let alone have control of my legs. My eyes would go evil vampire red because of how much the medicine dried them out. Basically I was gone for the night. And I got the best sleep! I was drugged out really. And of course as my dose went up the effect continued.

But over time, as the dose has steadied out, I’ve become more tolerant. I don’t get that drugged out feeling now, and I can stay up sometimes for a couple of hours after taking my night tablets. On occasion it does make me drowsy enough to start blinking heavily, struggling a bit to keep my eyes open, but if I really want to I can keep them open; it doesn’t overpower me like it did before. It still helps to give me a good nights sleep, and without it I sleep pretty lightly and spasmodically. As I experienced last night, because after taking my night dose in the morning, I had to take my morning dose of valproate at night to keep the balance, and one tablet isn’t enough to sedate me; plus I had no quetiapine in my system.

So, I took the wrong dose, and didn’t manage to catch it before it got into my system. And now I have to go to work. Well this should be fun! Here’s hoping I can fight the effects for more than a couple of hours.

Okay, next strategy: a large Coke, no ice from Maccas. Hopefully the caffeine will do something!! I drove all the way to work (I was questioning whether that was a great plan, but I felt fine at this stage) feeling okay, until the last 5 minutes when that warm, fuzzy, about to go to bed for the night feeling settled in. I got a little lightheaded on standing, slightly dizzy if I turned my head quickly, and just plain drowsy. My eyes wanted to shut and go to sleep, my thoughts got a bit thicker, I was trying not to speak slower. I hope to goodness I managed to pull off looking as enthusiastic and committed as I wanted to. But there was a big challenge waiting for me. Most of the 4 hour shift involved sitting at a bench reading policies and procedures and signing off on them, and doing orientation quizzes on the computer!! I mean, seriously! Of all the days in the world, I really needed a stimulating day today, and I got reading of less than riveting material!! I think I pulled it off, I mean I got it all done, but I have no way of knowing whether I was doing it way slower than usual, a bit slower than usual, or how many micro sleeps I had sitting there at that bench! Luckily the chair was very uncomfortable so that keep a bit of an edge on my alertness, and after 2 hours when my supervisor went for lunch, I went out and got an iced coffee with plenty of sugar! I think that did help a bit to keep me going for another couple of hours! Plus the fresh air was good.

Yikes!! What a day! But I did survive, somehow, by some miracle, and I’m going back on Tuesday after the Easter break. To be continued.

Did I come home and go straight to bed? Yep, you betcha! A couple of hours sleep did wonders. Usually I can go straight back to sleep at night after an afternoon sleep because of my night tablets so I did struggle a bit getting to, and staying asleep without them. But I didn’t struggle catastrophically. I think I actually had a pretty good night’s sleep in the end, although I was awake from 5am on the dot this morning, Thursday 13th April.

I can’t double up once I’ve taken the tablets, even if they were the wrong tablets. So what’s the plan to get back on track from here? Most of my tablets can only be take once in 24 hours meaning I can’t take night tablets again today. So I’ll take my morning ones tonight, then my morning ones in the morning (the morning doses are smaller so it won’t be such a big deal taking them back to back) and my night ones tomorrow night; then I’ll be back on track. Until then I’m sniffing my head off because of the longer gap in between doses of quetiapine, from morning one day to evening the next. It usually dries me out so sniffing is unusual and annoying! Apart from that, and the obvious drowsiness there shouldn’t be any consequences from stuffing this up, luckily. When you take the same medication all the time, a one off dose mix up doesn’t tend to affect your overall medication levels enough for issues to arise.

And here it is 7am and I’ve written this blog and I’m ready for breakfast, bright and early. I could possibly be very productive without those night tablets, but it wouldn’t be worth it for my mood. Ah the catch 22’s in mental health treatment! 

So, have I learnt my lesson in being more careful? I’d like to hope so, but I find the lesson only lasts as long as my memory of it, and that’s a whole other story!