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.

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PSA

Here is my public service announcement (PSA).

Not to be confused with prostate-specific antigen, Pharmaceutical Society of Australia and I’m sure many other words starting with those letters positioned in that order.

Do you take any medication? Any medications?? Even one medication?

“No, only vitamins, no medications”. “Which vitamins?” “Umm…”

“Just a blood pressure tablet…oh I don’t know what it’s called, its the pink one”

“The doctor started me on an antibiotic this week, no I don’t know what it is”

Here goes, my entire public service announcement: KNOW YOUR OWN MEDICATIONS.

Every day, somewhere between 4 to 18 times depending on shift length and how busy the department is, I walk into an ED cubicle and ask a patient, do you take any medications? And I get some frustrating answers: frustrating in that the patient or their carer hasn’t taken ownership for their own or the patient’s healthcare, frustrating in that I have to put in a lot of time and effort that the patient didn’t think was worthwhile, and isn’t necessary, and I forget why else; I’m sure there was something.

 

I’m not whinging about having to do my job. The whole point of a pharmacist is to elicit the best possible medication history from or for a patient, and I have to dig a lot to get the optimal history. It’s the reason I go to work and the challenge of it creates a real sense of satisfaction once I’m certain of a patient’s medications. But I do think that patient’s have to be engaged and do their part. Obviously I cheerfully exempt unconscious patients, those who are demented/delirious, institutionalised patients and anyone else not in charge of their own medications. But the rest of you? Own your health, for your own sake if nothing else.

You don’t have to be a doctor, a healthcare professional or know anything really about medicine to excel at managing your own medications. You just have to put in  a little time and effort, and get to know the following: the medication generic name (the one in small print), or the brand name (I can work with that), and the strength of the medication. That’s it. I’m not even asking you to memorise it. In fact I don’t want you to rely on your memory. When you’re in the ED, there are so many things going on that with you that your medication name and strength are going to get prioritised right out of your memory recall centre, and be useless to both me and you! So write it down, photograph it, tattoo it on your skin if you must! Okay, the last one is a joke, people!

After that, I need to know a couple of things about each medication: how many times a day you take it, what time of day you take it, and anything else pertinent to the medication specifically. If its written down, all you have to do is hand me the list and that’s all I need; if its on your phone just hand me the phone. So if you don’t want me bugging you, and asking you questions, be organised! I will reward you.

And as an added bonus, if your medications are written out neatly and the list shows you know your doses, your medication chart will be written up quicker, more accurately and your medication chart will be safer. I think that’s worth some effort.

For instance, one patient today brought all of their own medications in a box with a handwritten list saying what time of day each was taken. I was able to record all the information I need: generic medication name, strength (from the medications themselves), and the amount she took and what time of day she took it (from the handwritten list) while the patient was sleeping. When she woke up, I just quickly ran through the list with her to confirm it was up to date, and that was that! Easy, fast, and done, just like that! Her medication chart checked for accuracy and the patient was safe to go to the ward, medication-wise.

A lot of patient’s are very good at bringing in their own medications. In fact Epworth patients are exceptional at bringing in their own medications. This is mostly because they know from their last admission or from savvy ambulance drivers that if they don’t bring their own we’ll dispense what they need, but they’ll pay the same cost as if they were getting the medication dispensed at their usual pharmacy. Most figure they’ll just use what they already have. But having all the medications together in one place at the start makes taking a medication history a lot easier and more accurate, so there’s a hot tip for you.

 

Let’s try this again: do you take any medications? Yes? So what are they? Acceptable answers include:

  1. Here is a photo on my phone of all my current medications including vitamins showing the medication name and strength of the tablet/capsule clearly
  2. Here is my medication list that I keep in my wallet/handbag/toiletry bag that I bring to hospital with the name and strength of each medication and what time of day I take them
  3. Here are all of my medications in some sort of bag
  4. Here is the name of the pharmacy where I get all/most of my medications dispensed regularly

Personally? I carry a list in a plastic slip case that I got the the National Prescribing Service (NPS): it has sections for medication name, strength, amount, time of day, diseases, allergies all neatly in a double-sided fold up sheet that fits into a plastic cover; I think you can get them from NPS online.

So even if it’s one, or two, or “just” vitamins/non-prescribed medications, take the time to record them some way, some how. This isn’t just for hospital, but of course this is from my perspective working in a hospital. But I’m sure your GP, your specialists, and maybe others will make good use of your medication recording. So get going, and do me proud! I’d love to see your efforts, so send me your best!

Accidents happen: Part Two

Did I say “accidents happen” the other day??

What was I thinking?!

It’s like saying its q___t at work; never say the Q word!! It invites chaos and busyness and problem scripts one after another. But I said accidents happen, and so they did! Fate heard me, even though I don’t really believe in fate…oops, is that another invitation to the world to punish me?? Well punish is a bit dramatic, but you know what I mean.

So I’ve been recovering from accidents and errors ever since I wrote about accidents!! It wasn’t enough that I had my first ever minor car accident last Friday. On Wednesday, I had to go and fall down the stairs!! Like a really idiot!

I think it was sleep stupor, but to be honest I don’t really know. It was morning so sleep stupor could cover it; not much of a morning person, me. I took one step down leading with my right foot, another step down now with my left foot, another with my right and then I just slipped off the far edge of the next step with my left foot and I was gone. Our stairs go halfway straight down, turn 180 degrees then the other halfway straight down. Pretty standard. I slipped on almost the last stair before the turn. It might have to do with the stairs being shaped as wedges for the turn and I hit the tiny point of the wedge. I don’t really know how but somehow my left heel hit close to the edge of the stair and just slipped right out from under me and slipped over stair after stair after stair with no grip on any of them. My left leg was a useless slippery pointy thing sticking out in front of me causing nothing but trouble!!!

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Brain kicking into overdrive trying to figure out what to do, hoping to hit the wall at the bottom of the first half of the steps, grabbing the railing by instinct rather than thought, left leg useless sticking straight out front and can’t get a foot hold anywhere, getting half a grip on one stair after another but slipping over each and every one, poor right leg tucked underneath getting banged and scraped stair after stair after stair!!

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Luckily, and there is always an aspect of luck with me somehow, I was trailing my hand down the banister and managed to grab it! And even though my grasp slipped down the banister, it got caught on the post halfway down at the corner and I managed somehow to haul myself to a stop. I’ve seriously wrenched my neck and back and arm because of stopping myself but at least I didn’t go head over heels or something worse. And at least my hand was in contact with the banister when I fell; usually I don’t hold on at all! So it could have been much worse. Apparently its a workplace OH&S recommendation to have 3 points of contact with stairs at all times: 2 feet and 1 hand, or 1 foot and 2 hands if you are that person who just has to push the envelope! So maybe I need to put up some OH&S posters in my stairwell!

Panic as several steps went by and I missed the wall at the end, turning instead to start going down the next flight! Finally gripping the railing at the post as I slid to it and holding on for grim death!! Or is it life? Either way, I managed to stop on that poor banged up left hip with my useless left leg still sticking out in front, and the even more useless right leg underneath and my arm twisted backwards at some weird angle. So by the time my hand found a hold on the midway post, I was through the corner and heading down the next straight with my right leg tucked well under me getting cheese grated on each and every step where the carpet is bare and the strings are coming through. Basically I got a combination of carpet burn and grating right down my shin and a good few bumps on my left hip, which is swelling up nicely. I was feeling pretty shabby!!

So I was pretty stoked to have come to a stop, even if it was at the cost of the whole left side of my torso and arm. But how to get up?? I’m not a little thing, as most of you probably know. And unable to engage to use of either leg and one arm and side made getting up some kind of origami exercise! I actually can’t tell you how I got up, but there were a couple of bad moments where I started to slide again. But here I am to tell the tale!

So I grabbed on for dear life and managed to stop my fall. There was a moment of real horror thinking that the post might let go; I definitely felt it give. But when I went back afterwards it was as solid as ever. But as it turns out 120kg dangling by one arm is not only a threat to the wooden stair railing but to the muscles and soft tissue behind my shoulder blade. OUCH! Before too long I couldn’t turn my head to the left more than 20 degrees, behind my shoulder blade was singing and I was rapidly becoming frozen stiff. So a trip to the physio to get ironed out.

To look at you can’t even tell I’ve had an accident. Well not until I covered the grazes along my shin with white dressings that is, they kind of stand out on my tan! Not intentional but there you go. It saves me feeling like an attention seeker telling people about my accident; the bandages seek your attention on my behalf!! Is that the same thing?

Its amazing the pain and irritation such superficial scrapes create. Bed sheets, leggings, any clothing just rubs so I headed down to the pharmacy for some dressings so I can at least be a bit more comfortable. Now at least the stinging doesn’t keep getting set off again. But stretching the skin by moving it any way including walking is still aggravating. So here we are, another accident. What to make of this one? I really don’t know what went wrong so that I can avoid it again. Just one of those things? Or I should take more care?

So that was my fall. I thought that was enough, how about you?

But no. I get to work and start my usual Thursday; you know, all the packs and stuff that I wrote about recently. Then my boss brings one of the packs to me and says it has been brought back to the pharmacy over an error! That shoots straight through the heart. Especially right on the heels of having experienced a dispensing error and making (possibly) a big deal about it. As it turns out I hadn’t seen that there were 2 loratadine (you know, Claratyne the anti-histamine) tablets instead of one in Tuesday morning. It’s a robot error, but my job is to pick up that type of error, and I didn’t.

I could justify my omission by saying that its not that serious an error; in all likeliness there would be no side effects as loratadine generally has no more side effects than placebo (sugar pill). But the point is that I missed the error.

I could justify it by saying that the patient hadn’t taken it yet so it wasn’t so bad.

I could also justify the error with the conversations I’ve regularly had with other pharmacists checking packs discussing how extra tablets in packs is the hardest error to pick up, compared to other errors: broken tablets, missing tablets, wrong tablets. But I still missed the error. Not good. But it has made me further reconsider my response to the dispensing error that happened to me.

But wait, there’s more!! Unfortunately.

This, I suppose, is what happens when you only work twice a week. Short of them texting you about issues on your days off (it happens!) they save them up for next time you come in!

So, it seems that I dispensed a patient’s 500mg Epilim (valproate) correctly, then attached the labels to 200mg tablets. THIS is a problem. This is a big problem. I don’t know why the patient was taking Epilim but irrespective, taking this error over weeks to months WOULD have resulted in a relapse had the patient taken it: a relapse of epilepsy resulting in seizures, a relapse of bipolar resulting in depression, mania or suicide or worse. As someone who takes Epilim and dreads the probably inevitable day that I relapse, I can totally empathise with the patient in this scenario, as well as my position as pharmacist!!

I could justify this error by…nope, nothing!! I should have scanned the medication against the dispensing; this would have shown the error. I should have compared the original script to the box of tablets to reconcile the strength; this would have shown the error. I could have reviewed the history, but that’s an extra step. All I needed to do was the 2 steps mentioned; that would’ve prevented the error. Luckily the patient identified the error, brought the medication back and no harm, no foul.

Sound familiar?? My high horse is sinking through quicksand and I’m about to go down with it, unless I jump off and acknowledge that I just made an error as significant as that other pharmacist, and how do I want to be treated over this? What lessons do I need to learn? How would I feel about being reported to the pharmacy board? My boss knows, so that aspect can’t get worse, but he was very good about it actually.

Can I console myself with the errors that I did pick up today? 5 missing doses of magnesium in one pack, 2 missing dose of metformin (for diabetes) in another, a broken Panadol tablet making an underdose, a broken clonazepam tablet (for seizures or spasms) underdose, double the Efexor (antidepressant) dose in one slot, a random thyroxine (for underactive thyroid) tablet found in a pack where the patient doesn’t take that medication, and more. Does it make up for letting a more severe error pass through to the keeper? In short, no.

But it does make you think. Here I am, on a squared playing field, accepting that human error exists but there are systems to obey to minimise it, and ignoring the systems is just not on!

Upbeat

Well let’s try something a little more upbeat, shall we?

– Amy Adams, Miss Pettigrew Lives For A Day

Time for some good news, don’t you think? The last 2 week’s blogs have been a tad depressing. But then again, that’s what we’re dealing with; depression. And it is depressing!

But, time for some good news. Just as long as you don’t think that’s how it actually works in real life. Good news following bad in a nice little ratio. It doesn’t happen neatly like that. The depressing topics can go on for quite a while without relief!

Thanks to my amazing psychiatrist I actually am feeling quite a bit better this week. My meds have been upped again and within 3 days of increasing the dose I was coming up from the depths and feeling better, and my energy and mood have kept on coming up. Thank goodness!

My belief has been renewed that it is possible to get properly medicated and live a reasonably normal life. I stopped believing over the last little while, thinking I was living a doomed life. I have been reminded how closely the analogy of diabetes fits my disease. When a diabetic’s sugar levels go off, they feel awful but they go to the doctor and the doctor changes the level of medication. I just forgot that I need to go to the doctor and ask for more meds when I start sinking; I tend to think it’s on me to fix myself, as if I could! I’ve been reminded very clearly this time that when I’m struggling, it’s not just that I’m struggling, but that there’s something chemical going on in my brain that needs a doctor to sort out. I need to recognize it, and ask for help. That sounds obvious, but it’s not obvious to me, not when I’m sick. I just blame myself, feel like I’m not doing enough to be better, and I hibernate.  So I’m reminded it’s the level of chemicals in my brain that are dictating how I’m going, and when I need more, I need more and I need to ask for it. I’ll try to remember for next time…

I have faith again now, faith that things can be better, and will get better, and will be better. Something I lost lately.

But if I wasn’t feeling better, I was planning to write something “positive” anyway.

You know, so you wouldn’t worry. So you wouldn’t think it was all bleak and dark. To balance out the last two posts. To alleviate your concerns and to reassure you that everything is okay. Because that’s what we do, or at least that’s what I do. People who are emotionally and mentally unwell.

I want you to know when things aren’t going well because I believe in my friends and family knowing the truth. I want you to know, I really do. I think it’s good for a lot of people to know how these things work; so you understand, and maybe so it’ll help you help someone else.

Until all the condolences roll in and everyone is so worried. Until dear friends get scared, and fret about how I am going. Then I think about you, and how it’s affecting you and it makes me anxious, thinking of more questions and concerns, and I back peddle. So sometimes I tell you its all good so you can relax. And so I can relax, and I’m no longer fielding afraid questions from loved ones. My husband says this is insulting to people. To coddle them, and not let them in on the whole truth. To decide what they can handle and what they can’t. To give them the amount of truth that I believe won’t overload them, and by extension, me.

I’m sorry to do this! I don’t mean to take control of the information stream, or insult you, or lie. But it quickly becomes too much for me. Despite this, I don’t want you to change a thing. Please don’t stop feeling concern, or asking me about what’s going on. I’m just letting you in on my crazy brain!

But I think this is a very common thing in people with mental illness. I read a piece recently about “smiling depression” and so many times it IS easier to smile. I try not to be fake, but it’s still my fall back, the easier option.

It’s not about restricting your access to information about my illness and how I’m going. Like I said, I want you to know; at least theoretically. I have a limited capacity for emotion, including other people’s, when I’m not well. This is why sometimes I still say “fine”, “okay”, “not bad”, “good thanks” to skirt the question of how I’m going. Because when I’m really not well, just a simple “how are you?” is enough to bring me to tears, and have I mentioned how much I hate crying? Especially in front of anyone else! But I’m trying to be honest and open, so bear with me.

Sometimes I want you to think I’m okay, or not so bad so I can slink back to bed without attention.

It’s not that I don’t appreciate your concern.

I want to promote understanding of mental illness, but sometimes the kind concern and loving questions, while so touching, are a lot to deal with when I’m operating at low emotional capacity! When I’m better it’s a lot easier to process and when I’m well it’s easy, just the same as you or anyone, but of course the same thoughts and  questions don’t apply then.

But I am well this week. I’ve got energy, motivation, stamina. I feel good! Everything is easier. I’m doing more, and it’s draining me less, and not exhausting me just to move. My husband is happy, the house is in a little bit shape, things are just good. So none of this is fake. These are the real positives that I can see clearly with my eyes right now. Yay!

  • I’ve gotten out of bed every day this week, and sometimes before noon! Really!
  • I’ve talked to a potential employer via email and on the phone, and done an in-person job interview
  • I’ve done groceries, dropped off some clothes to be mended, washed and dried sheets, posted some clothes for refund, tidied up my side of the bedroom, even cooked dinner one night! Don’t get your hopes too high though, that’s about all I’ve done!
  • I’ve been to my GP for an appointment, to a doctor for an ultrasound, to a careers counsellor for help getting a job, and to KFC when I couldn’t figure out what to eat for lunch! That’s a lot of outings and socialising for me! On the days I went out, I went to bed when I got home, usually for an hour and a half…but I didn’t nap on the days that I didn’t go out, so that’s something
  • All this out and about meant I got some sunshine on 2 separate days. Actually on the skin sunshine!

So that’s me for this week. It’s not a lot from the viewpoint of my old life, but these days I take whatever I can take, and this is relatively awesome!

How about you? How are you? I’d love to hear from you.

 

Tales of a missed dose

[Written 16th June 2015]

This is a story of what happens when I miss a dose of medication.

What happens depends whether I miss a morning dose or an evening dose. As I write this I’m suffering from missing an evening dose so let’s go with that.

At night I take several tablets: quetiapine, lithium, valproate, rosuvastatin, pantoprazole. Mood stabiliser, mood stabiliser, mood stabiliser, anti-cholesterol, antacid. Yes, it takes that many stabilisers to keep me going!

In the morning I take thyroxine, venlafaxine, Levlen, valproate, lithium. Thyroid hormone replacement, antidepressant, contraceptive, mood stabiliser, mood stabiliser.

All done! Hopefully...I'll still count the tablets out every morning and night to double triple check

In terms of missing a dose, lithium and valproate aren’t the worst to miss as a patient because I’ll be taking some again soon. This is not an official pharmacist, GP or psychiatrist recommendation! Lithium and valproate should ALWAYS be taken twice a day, as close as possible to 12 hours apart for the best effect! And I repeat! This is because for lithium a healthy person’s kidneys clear it out of you in that time frame so to keep a steady level you should take it consistently. And for valproate it’s your liver. That’s why you should respect these two organs very highly! They are very important. But what I’m meaning is its not the worst in terms of the adverse effect of missing a dose. If I miss taking lithium at bedtime, I take it first thing the next morning which gets it back in my system before I physically notice that it even left. My overall level will be a bit lower for a few days which isn’t ideal, but it will work back up to speed soon enough. And I do have a level at least.

Whereas for medications that I take once a day, I’ll miss the effect for 24 hours. Which sucks. Plainly and simply!

boxes, bottles, tablets, capsules

Quetiapine is one of the once a day tablets. It is prescribed to me to prevent mood swings, reduce my anxiety and has the handy effect of giving me a good night’s sleep. It was doing this a bit too well for some months there and I was doped out all of the time, but my awesome psychiatrist recommended a change in the times I take it and we’re back up to speed. Yes!

So, do I get a mood swing if I miss one dose? No. Really not. The chemistry isn’t that reactive. In the same way that it takes weeks of first taking the medication to get the benefit, it takes longer than one day to mess up the whole thing. But I do have a rough day afterward, and a rough night too! It’s a bit like I’m sitting in my car going along nicely and I know where I am and where I’m going and how I am and suddenly another car rear ends me, or bumps into the side of my car at a right angle. Slowly of course, not fast. So my mood just takes a hit, a bump and suddenly I’ve jumped along or across and I find myself somewhere other than where I just was, a bit disorientated about how I got there and sort of catching up with what just happened and where am I now and how I am and are we still okay? That following day I may be in quite a different mood from the one before, either peppy and edgy and anxious and manic, or slow, and silent, and flat and a bit away with the fairies. But that doesn’t qualify as a mood swing, just a sudden small change that affects my day.

After missing a dose here and there I have now gotten the side effects of missing my nightly dose of quetiapine down in a pretty clear timeline. Yes, there are side effects from NOT taking your tablets, as much as taking them. Something to consider.

So here’s the quetiapine absence timeline.

strips, tablets, capsules

10 to 11pm: I can’t get to sleep.

This is a terrible thing. I need my sleep. Always have, and always will I guess, but especially since I’ve been sick. So does everyone, I realise. If I don’t get a good night’s sleep the next day is a struggle, emotionally. So I toss, and I turn, and I turn, and I toss. After an hour of this, if I’m alert enough, I’ll think to myself, self, why can’t I get to sleep? I usually go straight to sleep! Then I’ll look in my pill box, see my tablets, mentally or physically hit myself in the head, take them and all is good in the world. Just like that. If I’m not thinking too clearly, I might think to take a Valium and at least get some sleep. If I’m dull-witted, which is at least half of the time, I’ll eventually wrestle myself to sleep. It sounds funny to say, but I’ve become very good at putting myself to sleep. I nap most days from necessity, and there is a skill involved in going from activity to sleep in a short space of time. I guess shift workers eventually excel at this sort of thing. So I’m quite adept at getting myself in a comfortable position, getting the temperature right (cannot sleep well unless it is right!), darkening the room, doing a conscious relaxation of as many muscles as I can, and stilling my mind into sleep.

Say I managed that. Next time check?

3am. Yep, wide awake, fresh as a daisy, ready to go at 3am. I toss, and turn, and can’t get comfortable, and I’m restless and my poor husband is rocking and rolling every time I turn and I’m messing with his sheets, and he has to go to work tomorrow even if I don’t, so I try to lay still and physically can’t! Why am I awake, I’m usually asleep, what is happening, oh….ahhhh! Tablets! I forgot them! Duhh! I hate that moment! I try to do my utmost to prevent it, but it still happens and it does feel like a failure every time I somehow mess it up! So, should I take them now? The dilemma! It’s 7 out of 12 or 24 hours through the medication time period. So I can’t take all of them. Maybe just some of them. Can’t take quetiapine, I’ve missed the boat on that one otherwise I’ll sleep all day. And I’ll be taking lithium and valproate soon anyway, and can’t double dose. What about the rest? Which are nothing really, in the scheme of me being wide awake at 3am! Cholesterol and stomach medication. Sure I can take them, they should be taken regularly but it’s too late for my sleep. The next dilemma then: try to force myself to sleep again, or just get up, take my laptop to the spare room and do something else? Who knows? Depends what I’ve got on the next day really. I can never decide!

medication list

8am: I’ve finally given up the ghost on sleep so I’m up and peppy and full of life and only just partially anxious and ever so slightly manic and energetic and going to run the world! If I haven’t already taken one to sleep, now is the time for a Valium to wind back the jets on being super woman and achieving all my life goals in one sweet day! And talking my husband’s ear off and planning one hundred chores like a complete going through of the entire kitchen plus 3 loads of washing on a rainy day and lunch with girlfriends and all kinds of magical things. ‘Woah, says my husband, that’s too many things for today. No do that another day, you’ve got enough things for today. How about you sit down for a minute, what about some mindfulness? I think you should do some mindfulness…how about you go and do that now?’ At around about this point I have now blown my nose for literally the THIRTIETH time since waking for the final time. THIRTY. You just can’t blow you nose till it feels empty; there’s always residual. And it’s pretty much like a tap. The medical term is rhinorrhea, like diarrhea but your nose is melting and there is a constant liquid dripping, dripping, dripping!! Quetiapine dries you out like anything so you get dry mouth (and want to drink Coke all the time!), dry nose which leads to sores and blood noses, some degree of constipation which no one wants to know about and some urine retention. The last one isn’t noticeable on any other day, until the missed dose day and then I realise that yes I really have been holding back! TMI I know, but you wanted the whole story right?

But the nose thing really gets me! If I notice nothing else in the middle of the night, I do notice my nose dripping incessantly! It’s an instant giveaway! It’s different to regular waking up in the morning and blowing your nose. It’s more like hay fever without the sneezing but the medication to stop it cannot be taken til nighttime!!! Cue fierce under breath bursts of ‘idiot’!

And then it’s just getting through the day like usual, but bearing well in mind that you’re a bit high today, a bit edgy, a bit fiddly, a bit anxious, a bit overstrung so remembering to breath, relax, calm, easy, gently does it. And I should mention that the other things ease off too, just not in such an obvious diagnostic way. I have the right amount of saliva in my mouth (who knew that was a thing!) and going to the toilet is a breeze, like really easy, like maybe a bit too much and too many times! So happy thoughts!

medication box, tablets

Now the morning lot and venlafaxine. Anyone who is involved in the prescribing, dispensing, and before too long taking venlafaxine knows about the withdrawals. It’s described in the textbooks and it happens like the textbooks. Exactly like. I used to think this was pretty cool. I still do theoretically, but in practice I either love or hate that they’re so reliable and unavoidable. I love them if I notice it before I’ve left the house for a work day because I immediately fix the shortcoming. I hate them if I notice once I’m already on the way to the bus stop and I don’t have time to turn back, or I’m on the bus, on the train, on the tram, in the building. Then it sucks because I know what’s coming and I can’t do a thing about it! Unless I can get to my doctor for an emergency script but that means paying full price, and after all it’s nothing life threatening. Not bad enough to pay three times the normal price! And believe it or not borrowing stock from the shelves is not strongly encouraged by my employers nor is it in any way legal!

What the symptoms/adverse effects of missing venlafaxine are: electric shocks/tingling in your fingers, light headedness/feeling like my head is spinning/wondering if I’ll faint, nausea. Nothing fun. Nothing dangerous. They don’t make for a good day, and I have to wait til the next morning to fix it! More banging of palm to forehead and severe muttering to oneself!

So that the what. The why is a whole other adventure and I don’t have time today, but hang in there and soon we’ll have another chat and look at the other part of the problem. Chat soon!

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.

Unwilling or unable?

Unwilling, or unable?

This is a difficult call to make.

It’s so subjective.

All that we have to go on is my opinion versus your opinion, with whatever evidence each of us has gathered plus whatever balancing knowledge we have at the time the call is made.

It’s something that I’m still battling with, and because I’m battling with it, I assume that there are others out there fighting with themselves over this. I don’t know for sure if there are, but I’m writing this anyway, for me and for anyone else who gets it.

Before I got sick. Such a statement! Also hard to define but I’ll use it anyway.

Before I got sick, I found this line easier to determine.

I’d get home from work, tired out and ready to relax and the thought of having to get together the where withal to get up and going again seemed impossible. Everyone has felt like that at some time.

So it comes down to a battle of the will.

I know I’m tired, will I allow myself to sit down and relax or will I get myself up and going to an exercise class I love and know I will enjoy/the supermarket for groceries to make a better dinner/the week night Bible study meeting which I’ll feel so refreshed after?

Will I, won’t I, will I, won’t I? It was a mental battle. From experience I knew that if I pushed myself I would get through whatever it was that I had planned on doing. It wasn’t physically impossible despite my tiredness. It was a matter of setting my mind to it being a non-negotiable task and doing it! Like work. You don’t wake up in the morning and think will I, won’t I go to work. You just get up, do what you have to to get organised and go!

Well at that stage I did. As the stress of my last job accumulated and compounded I did find myself waking up with a feeling of dread (hello anxiety!) and thinking do I really have to go? What if I just don’t go? What if I say I’m sick? What if I just stay in bed instead?

I guess I should have known that that was something else. That this was more than usual reluctance to get out of bed. I’ve always been a mid-morning person. Getting up has never been easy, but then again it had never been like this. Lying in bed watching the clock tick around to when I should be leaving. Feeling dread and stress and fear with a little smidgen of hope build up until I thought they could physically burst out of my chest.

But in our house growing up, the words “lazy-bones”, “wuss”, “sook” were tossed about like “hello”, “goodbye” and “how are you?”. As a consequence of those terrible words being acceptable to apply to children, I always question my own judgement towards myself, and wonder if indeed I am being a “wuss”, a “sook”, “weak”, “lazy”, lacking in having a backbone or courage or dedication or commitment or appropriate drive?

I think I’m learning these days to give myself more credit. To remember that I am a dedicated, committed professional who knows her responsibility in the workplace and fulfills her duties creditably; who wouldn’t “slack off” or “be lazy” or “not pull her weight” unless there was a solid decent reason. All words that no one else has used against me by the way, except for my old inner voice that I’m slowly chipping away.

I’m learning to know my limits and to communicate these to others. Not with the phrase “sorry to be a wuss but…”! With the phrase, “I have done x and y and z today and I’m pleased that I have accomplished so much. That is all that I can manage today. Thanks for your understanding”.

I think it’s called being assertive. Having been terrified of confrontation all my life I never really got the practice of asserting myself. I knew the theory but that only gets you so far. These days I’m realising that I am a person with valid opinions and thoughts. I’m finding that communicating this directly to others results in a better outcome for everyone. And I’m not so fearful of confrontation anymore. Because now I know that I am an equal part of the conversation/discussion/interview. I’m not the weaker part having to make up to the stronger part anymore. These are truly great days for my personal development!!

But it still comes down to this: what and where are the limits?

When is it enough without being too much? When could I push myself more? When am I taking it too far and risking exhaustion? Do I have more energy than I think I have? Could I maybe do just a little bit more, or should I call it a day?

How can anyone know the answers to these questions?

And then there are the other factors: I just don’t feel like talking to anyone today so I don’t want to go, I feel very anxious about going so I think it’d be better if I stayed home, I just can’t get my head together to go today, I’m too drowsy/sleepy/exhausted/tired.

I’ve been told to push myself, but to be careful not to exhaust myself. I’ve been told to learn to know my own body so it will tell me when enough is enough.

Who teaches these things? How can I learn these things? How can I know the difference between my body being tired and my mind being tired?

My body tricks me all the time. I’m sitting here an hour after a good dinner and my body is telling me it’s hungry. I know its not, but that’s not how it sees the situation! So how can I be sure about my body telling me when it has had enough? It feels like a marathon getting up, showered and dressed some days; my body tells me that it enough but surely that can’t be the limit.

If I can’t tell the limits, how can anyone else? I suppose this is my main point after all. Here’s me: I’ve got these limitations of conditions, medications, recuperation. How, considering all the variables, can any other person tell me what or how much or where or when I should be doing what I’m doing?

Not that many have tried, to give credit where credit is due. Most people have been endlessly helpful, patient with me in my disability, considerate of my limits and thoughtful of me in the middle trying to make me work.

I really do appreciate that!!

I guess it’s always a work in progress. The fact is that I can’t do everything that I would like to do; that’s just how it is right now. I am learning to accept these facts as they are without judging them or myself; that’s huge progress!

With the energy and motivation I do have, I do what I can. I get tired and worn out faster than I’d like. I don’t have the stamina I want. Some days I wake up and it’s just not my day. Then after a nap suddenly I’m firing on all cylinders again. And tomorrow, I might be rearing to go! I just don’t know, and can’t tell. It’s a trying, sometimes frustrating game trying to figure out my agenda for the week, or even the day, not knowing when or how or what I’ll be like with any definite prediction.

Another thing that it is very hard is to differentiate between what the condition causes and what the medication causes. Am I suffering from a side effect, or is this just the part of the condition that we haven’t got under control yet? I think only a trained doctor could answer that with any certainty, and maybe not even then.

So, in the meantime, I hope I’ll do what I can, but not too much, and hopefully figure out just what that is!!