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!

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Pregnancy

What could I do, I had to like it! It just made me think of myself, in a kind of funny.kind of truthful way!, gorilla, grass

What could I do, I had to like it! It just made me think of myself, in a kind of funny.kind of truthful way!

This popped up in my Facebook feed the other day from Brindabella and I actually laughed out loud! The expression ‘lol’ is so overused online that it has lost all meaning, but this is one situation where it was actually appropriate.

I laughed because over a few months I gradually increased in weight  until suddenly one day I looked in the mirror and realised I looked like this! Not a fun realisation! I mentioned it to my hubby and he agreed that he’d thought for a while now that I looked pregnant! Always helpful but he was kind about it. But its the truth so what can you do.

I should clarify here that I’m not pregnant; the weight is due to indulgence, medication side effects and the symptoms of mental illness. Just to be clear.

But anyway, somehow being that shape and seeing this gorilla translates to funny in my brain…not sure why, but I guess it’s amusing to see yourself mirrored in another species, and to see a big round belly, flabby arms and a double chin on a cute-ish animal looking equally unhappy about the situation!

The weird thing is, I know I’m overweight to the point of exploding over the obese line. But somehow my brain hasn’t caught up. Maybe because it happened so fast and unexpectedly, maybe because I’m in denial a bit…not sure why. I kind of knew already that my brain was lagging behind, but it became most apparent when I was in Thailand recently. Sitting on the boat in just my bathers, swimming in the pool, jumping off the boat into the water carefree and happy in front of everyone else, walking around at lunchtime feeling completely comfortable with my body the whole time. Which was a really nice feeling instead of hating it and wanting it to be different.

Until…I looked back and saw the photos! My big round tummy, double chin, fat cheeks and eyes deep in puffy sockets…ergh! Then I was not happy! Then I was not comfortable with my figure! Photos are kind of the cold hard truth that shoot you down out of your dreamy sky and bring you down with a big hard bang to reality!

I can kind of understand the idea behind body dysmorphic disorder now. I don’t have it and I’m not suggesting I do…but the brain is powerful and can really twist reality sometimes. To be one way, and consider yourself to be another way is…well in this case it’s kind to me to a point, but I guess when it comes to addiction or something like that it is very unhelpful, because you think you’re okay when really you are not. It can be unhelpful to me too I suppose, because when I’m looking at a block of chocolate I think it’ll be okay instead of considering my obesity and how chocolate is really not okay!

Here’s the other thing. When I was first really unwell, the psychologist and the doctor and all the self help websites told me to do nice things to and for myself to help me feel just a bit better. Have a bath, eat your favourite food, watch your favourite show, go to your favourite place either physically or shut your eyes and imagine you are there. So chocolate, a hot chocolate, a bowl of yoghurt…whatever you love, was okay to eat anytime and all the time to help get you through the difficult days.

Except there was no limit put on that habit…so I just kept going and going. A limit would have been good, but realistically I was unwell for months while we tried fluoxetine, venlafaxine, sertraline, sertraline plus mirtazepine, sertraline plus quetiapine, desvenlafaxine plus quetiapine, reboxetine plus quetiapine and full circle to venlafaxine plus quetiapine and finally venlafaxine plus quetiapine plus lithium, the best yet! All of those antidepressants working a bit or not much, until finally the correct diagnosis of bipolar and the life-changing prescription of lithium.

And still the end date for self indulgence hasn’t been set.

I’m better; I’m not back to where I’d like to be. I have more energy; but still need my daily naps. I have more resilience; but some days I just need something external to make me feel better. I’m trying to cut down on my treats and snacks; but it’s hard!

And here’s my shortlist of how fatness that looks like pregnancy is different to pregnancy:

1) In pregnancy, you know what to expect and you prepare your body. You moisturise and Bio-oil your belly to prevent stretch marks. In fatness, stretch marks pop up out of the blue completely unexpected and you have no warning to prepare for that.

2) In pregnancy you get the baby most times, not always. In fatness you just have the rumours, the questions, the look without the baby at the end. To be honest, I haven’t decided whether I think this is a bad thing or a good thing….I’ll get back to you.

3) In pregnancy you deliver the baby and the belly size reduces a bit, then gradually reduces slowly back to somewhere near where you started. In fatness, these is no initial tummy reduction; you just start from wherever you are and gradually reduce it hopefully also to somewhere near where you started. So actually, the two conditions can be pretty similar in this regard.

Well that’s about all I have to say about fatness and pregnancy at this point in time.

I started and stopped the gym, I did a few food coaching sessions, I returned to pilates for a bit, I go on and off calorie restriction, we’re trying to do daily walks, I’m trying to get back on my bike on the trainer in the shed, I’m trying to walk past my favourite snacks.

It’s a work in progress; I’ll get there one day. And for now, my attempt is to be kind to myself and remember why I came to be where I am, and whenever I can, to do bits and pieces to help me along the way to getting where I want to go.