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.”

Victory Part One

[Written 20th June 2015]

Victory is mine blog post

Okay that’s not going to be my title, way too grand and pompous for my usual style. But today was a victory and I want to talk about.

I was meant to restart work sometime last week. It was always a vague plan of sometime after the Queen’s birthday public holiday. From the time I took back my authorization to get a police check and stat dec to say that I wasn’t an awful criminal the suggestion was it would take the HR department about two weeks to prepare the contracts. Oh, and by the way, the hospital executive have just put a halt on recruitment until the end of the financial year! We may sneak in, we may not.

So it didn’t happen last week, and it wasn’t looking super likely for this week either. So my plan? Bike ride as much as possible until I go back to work! It is still amazing to me that I, in the dead of winter, in shall we say frigid conditions with rain and bleak outlooks and low teens temperatures, would be keen to get out there and get cold and exert effort! Crazy! Yet it turns out that my week is built around it! I would NEVER have thought that this would actually come to be in my life!

I mean, yeah, they said exercise was good for you and helped your mood and did wonders. I got started at the gym after moving back to Melbourne when I was beginning to put on weight in a vain attempt to keep that at bay. I did enjoy the classes, another women’s only special, and afterwards I loved that I’d been able to do it. My post-gym face made it into a couple of my ‘100 happy days’ posts. I made an effort to get to my classes after work, which was a tight squeeze, and then when I wasn’t working anymore I tried to get there and do the solos workouts my friendly coach had designed for me. But the cardio stuff sucked! I’ve always been good at weights and they are my preference. But right then, with the weight I’d put on and as the sedation overcame me, cardio was just a punishment! So I put the gym on hold, and it stayed there. My psychiatrist agreed that I shouldn’t be pushing myself with the gym and suggested walking each day.

Walking. Okay, seriously! I have a green, leafy park that I can get to, walking, in less than two minutes. It’s one of the awesome conveniences of where I live. Theoretically. There’s a beautiful walking loop made from perfectly poured, on camber concrete with an inner spongy lane perfect for running. It has marked distances and revolves around a pretty little lake with ducks and a foot bridge, a community exercise area always in use and a children’s playground. Perfect.

Two minutes to the park. Five minutes to the hospital, twelves minutes to the train station and supermarket. That’s my house.

But I don’t like walking anymore!

I used to walk up hill to the train station to get to work every day, from October 2013 to March 2014, and I just did it without thinking. Then I walked around the hospital all day often clocking up half my daily step count and a couple of kilometres. I’d often take a walk for 20 minutes under the Moreton Bay fig trees to chill out at lunchtime which was lovely, travelling from Commercial Road to Toorak Road and back, then walk back down the hill again to get home. My Fitbit got to 10,000 steps every single day and often quite a bit more. I was doing great physically and was in the shape of the last 10 years! I’d just spent more than 18 months up to August 2013 exercising and dieting my way to 78kg which was a 15kg effort that I was very proud of, and got me within a few kilos of my ideal weight! So I was enjoying my hard work.

But as I got sicker, my motivation and energy flagged and I started putting on some weight, and that morning uphill walk was taking me longer and was getting harder. I started to dread it! My breathing was way harder than before, my heart felt like it was about to hit the absolute red line or die altogether, my legs rubbed and chafed and turned to jelly mush, and I just didn’t want to do it anymore. Besides I had to conserve energy; I had the whole day still ahead of me!! I didn’t want to walk; I wanted to catch the bus. Once I did, there was no turning back. I would wait 15 minutes at the bus stop for a 7 minute bus ride that was full to overflowing where I sweated up a storm in the crush of body heat, rather than walk 10 minutes home, even though it was downhill. At that point, it didn’t matter whether it was uphill, downhill or neutral; I hated it!

I’m working on this. I wear shorts or leggings, I take my time, I breathe it out, I remember that my heart is actually a surprisingly resilient muscle and no one has ever yet died from it jumping through their throat into the open air and flying away! That last one is difficult and takes a lot of mantra-like chanting inside my brain! I will not die, I will not die, and I will not die.

We did an impromptu walk with friends a couple of months back. It was described as an easy walk, but that was their opinion not mine. They set a cracking pace over difficult terrain and I wished I was dead! Halfway through the caring mother figure asked me quite seriously if I was going to have a heart attack!! I was so red in the face I probably looked like I would in fact explode, I was dripping sweat, my feet and legs hurt…la, la, la; it wasn’t that much fun, apart from the scenery.

Cue the bicycle. It came to me, I now realise, at the perfect moment in my journey. I’d seen an ad for She Rides earlier and instantly dismissed it. The fact that when it came back around on Facebook, or email, or something else, I actually considered it, showed that I was in a place in my recovery where I was starting to open my very closed mind to the idea and possibility that starting gently into some exercise could really be something I could a) do, and b) maybe, somehow, I don’t know but people assure me I could, actually enjoy! So I tentatively put out some feelers. I’m not a committing person! I have to do a lot of thought before I jump in, and even then it’s more of a slow trip and fall that accidentally turns into a jump!

Ask my husband: we went out for 7 years before I “jumped” in! At least we got through the whole itch thing first. In that last year when it was blindingly apparent that of course we’d be together forever, and no sinister cosmic plan was floating through the universe waiting to hit us with its deadly and devastating bolts, or anything along that drastic and dramatic plane of thought, I gave my husband a model snail. I told him please wait, I’m getting there, I’m coming; it’s just taking me a while! That’s how I am, but I’m working on it. I can impulse buy now, not that I’m sure that’s a good thing! There are shops in Shepparton where I grew up probably sick of the sight of me, coming back for the third time to try on the same pair of shoes “just to see” if they were any different from every other time! Procrastination is what it’s really called, and it has gotten the upper hand of me in a lot of my life, but I’m working hard to crush it!