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.”

Accidents happen

We all know this: accidents happen. It’s part of life.

But in some areas, accidents aren’t okay. So we make systems and safeguards and policies and procedures and checks and balances and we educate to minimise human error. Sometimes, even that isn’t enough.

I know mistakes happen. This week I had my first ever car accident. I’ve had plenty of near misses and close calls in the fourteen years since I got my learner’s permit, but luck has always been on my side. I did have to run off the road once when someone stopped dead in front of me on a 100kmph road…but apart from having a panic attack from a massive surge of adrenaline after I finally pulled the car to a stop in an orchard, there was no harm, no foul!

This week what happened was that my left front tyre slipped on the soft edge of the road made up of leaf litter, and despite me pulling on the steering wheel and braking hard I slid off the road into the shallow ditch and hit the bank on the other side! It was sort of interesting to note that the wheels did turn; once I got out of the car and found that my knee was just bruised, I found that the wheels were in a slightly turned position but obviously I just skidded. Luck was still on my side though: the side of the road, the mini ditch and the wall of the ditch that I ran into were all so soft that there was almost no damage at all, and I wasn’t hurt. In fact when I eventually got off the wall, it was running water; there was practically a river of water running out of it! The unlucky part was that I “crashed” (a dramatic word for sliding off a road at slowish speed) in the back of beyond on a road very infrequently used with no internet or mobile reception and no GPS! Couldn’t call hubby, couldn’t call RACV, couldn’t call work to tell them I was a bit delayed; nothing! I couldn’t message through Viber, Facebook, Twitter, Instagram, Gmail; nothing! No one could track my phone by GPS. So I had to sit there and wait. And wait. And wait! In the end I had to wait half an hour before the next car came along! Still, it could have been a lot worse.

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Doesn’t look too bad right? Just resting here…

 

I couldn’t leave the car to find better reception, even locked, because I was halfway between picking up a bucket load of drugs and delivering them to my pharmacy! Imagine: I’m a pharmacist in a new job, trusted for the first time with a pick up, and for the first time I have an actual car accident!! Not cool! Someone asked me if I told the boss…um no!! Sure I could get him to pay the repairs, but do I really want to start with that kind of problem two and a half months into my job? Please note this drug/medication transfer was a one-off event; my car is not usually filled with drugs!!

So I sat there. I yelled out loud at the top of my lungs a few times for no one to hear. Just expressing my frustration in a civil, calm manner. I tried slowly reversing back without spinning the wheels but the ground was too wet and the leaf litter was too deep; the front wheels gripped for a millisecond but slipped almost straight away. Pretty sure the back wheels didn’t budge…well of course they didn’t, its front wheel drive; duh!! My years of bumping around our block on the old Fergie tractor have finally come to some kind of use, especially that time I had to back myself out of an actual metre deep ditch! But it had better wheels more suited to this kind of situation; it could practically climb a wall! The leaf litter on the edge was so deep that when I stepped out of the car my foot went right down into it. I tried to push the car back out of the ditch from the drivers seat, I tried to push it from the back seat but it didn’t budge…oh whoops the hand brake is still on! Kind of redundant since I’m resting on a bank. But letting it off didn’t help, and whats that on my foot? EEEEK!!!! Screams at the top of her lungs!! A leech!! SWAT!! Thank goodness that’s gone. Oh no its on the steering wheel!! SWAT!! Now its on a different part of the steering wheel! ARGH this leech is a real sucker!! Who would have thought?! Jumps out of the car out of impulse trying to get away from the huge, enormous, blood sucking monster!! Almost as bad as a spider at close quarters!

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The exact view from my car window…so it wasn’t all bad!

 

 

Oh wait, what’s that?? A 4WD or ute or something big and heavy and revving is coming down the hill! Start waving, start waving!! Yes its a cab ute with 2 men and a towing engine thing on the front and a solid tow rope with a huge hook…oh yes, this is what I’ve been waiting for!! Waving, waving, getting out of the car, please help me!! It occurs to me belatedly…that I am in a deserted part of the world, with no mobile or internet reception, asking 2 men for help in a situation that I can’t help myself out of, and trusting to their good nature. When I was suffering anxiety, I would’ve been hiding in the boot of my car til sundown and my husband realised I was missing and sent out a search party!! Actually no, my boot was full of drugs…well maybe the back seat then. It just shows how far I’ve come, and that really most people you run into are good.

The driver’s reaction when he got out of the ute? “Oops!” Precisely, my good man! But he said he had the same accident on the next corner himself last year, so I felt better. Because of course up until this moment I had naturally assumed that this was the exact kind of idiotic, stupid thing that I always get myself into and no one else would ever do such a dumb thing and wasn’t I a prize numpty?! And that this was yet another episode of me damaging the car, because there have been many! Part of my reasoning for not telling my boss; assuming that I would be embarrassing myself! Not that I actually did anything, I just sat there while I slid in the mud. But I always insist to myself that I’m the one that stuffed up. So these 2 kind men dragged me off the bank backwards with tow ropes, but the back of the car was slipping into the ditch now, so we had to switch to dragging the front up onto the road and the rest of the car followed. Meanwhile whatever hound they had in the compartment on the tray of the ute was howling at me as loudly and as often as it could breathe!! Another piece of luck was going off the road while it was still bituminised; another 500 metres and it turned to packed dirt…pretty sure that would have hindered the towing process. So 45 minutes of my life and I’m back on the same bit of road I was before the accident.

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So I displaced the bank, and a bit of my bumper…not a bad result

As it turns out I shouldn’t have even been on that road! I turned 150 metres too soon, and should have been on Maroondah Highway where this would never have happened. Ahhh. But I definitely got the scenic route, although I probably would’ve been happier swapping a bit of scenery for a car trip with no accident. Only something that would’ve happened to me, or just an unfortunate happening that could happen to anyone? At least I didn’t have to get towed with all those meds on board!!! THAT would have been embarrassing to explain to the boss!

So with all this in mind, I’m still unhappy about an error that occurred today. I got several scripts dispensed at one of the pharmacies I routinely use near my GPs office and one of them was wrong. Not a little bit wrong like the price was out, or I was given the wrong quantity. I was given the wrong strength of lithium, 450mg instead of 250mg making it an overdose, and it was the slow release formulation instead of immediate release meaning it would hang around in my system longer after the overdose, and it had the usual twice daily directions that apply to the 250mg strength instead of daily which is how the 450mg slow release should be taken so the level of lithium in my system would accumulate quickly. My lithium level is already at the upper limit of okay, and my psychiatrist is thinking of reducing my dose; this would have found me in hospital within 3 days!!! It’s that serious, and potentially worse.

But I’m conflicted.

As a patient I’m outraged and think the pharmacist should be reported for this very serious error, that fortunately didn’t eventuate because I picked it up before taking it. I think that there should be some consequences for not taking the proper amount of care.

As a pharmacist I know how terrible I would feel if this were my error, but I also know that lithium is one of those medications that you should take extra care and attention with when dispensing. The error occurred because the pharmacist entered the wrong medication when typing, and so the scanning check wouldn’t pick this up. But there would have been a message saying that I previously had a different strength, which was ignored. And my history must not have been reviewed before dispensing, despite it popping up and having to be entered through before you can type in anything. Two checks ignored, besides the obvious check of visually comparing what is written on the script with what is typed before printing!! That’s three checks ignored. I’m not sure the the pharmacy board would see any reason for skipping any of these checks, especially as there were only two patients in the store at the time.

So this is my big beef with pharmacy at the moment, both in my workplace and in the pharmacies where I get my scripts dispensed. There IS a proper way to do pharmacy, and it’s not being done! For reasons which are specious and inadequate, and I believe, unacceptable! I miss hospital pharmacy for this reason: maybe we take more time but we do things as properly as we can, no shortcuts or conveniences. Of course the pharmacist felt terrible, its a natural reaction. But will it change her future practice? Will she do things properly next time? I really don’t want to report her, mostly out of colleague empathy. But is it something I should do, for the improvement of the profession? I probably won’t, but it’s still all milling around in my mind.

What’s an accident, and what’s an error? What’s okay and what’s not? Should I be pointing fingers when I make my own mistakes? I don’t know. What do you think?

The big return

I had planned to make a big announcement about my new job when I started, just before my first official shift, but anyone who reads my blog regularly already knows about me starting work because I told you recently because of a blunder, and, well, anyone else just found out! So no announcement. Just a reminder really that I am OFFICIALLY starting my new job on Saturday 29th April, 2017.

My official pharmacist coat, the first time I’ve gotten to wear the traditional garb; my keys to EVERYTHING; a pink, personalised name badge; pocket with a pen holder, and I’m ready to go!

It’s not such a big thing, really, as I’ve already done 8 shifts over the last few weeks. Wow, eight shifts already! That crept up on me. Five of them were half days, but still; it’s work! I was really thankful that my new boss was as keen as I was for me to get in several practice shifts before I started, and it has helped me to feel comfortable and confident heading into my first shift. It has given me a chance for reacquaint myself with the FRED dispensing program, although pretty much nothing has changed since I last used it in 2009! It’s such an easy to use program compared to the 2 hospital pharmacy programs that I’ve used over the last 7 years, and nearly all of the scripts scan in; no typing involved! So cool! I’m still in love with this function!!

My name up in official pharmacy lights!

It’s given me the opportunity to learn the “order” of how drugs are arranged in the pharmacy. This is one of those words that means the opposite of what you would think…oxymoron? I think that’s the word. See whereas hospitals organise their medications sensibly by the drug name (generic name) in alphabetical order, community pharmacies have ridiculous systems, and no one, including those that work there, really know why they have such a dysfunctional “system”, and the system is different in every pharmacy.

In this pharmacy, originally drugs/medications were ordered A to Z by brand name, instead of generic drug name. Fair enough. Back when, before additional brand names and generic brand names, there was one brand name for each drug and everyone knew the brand name for each drug. Drugs were marketed by brand names and that’s mostly what they were referred to as by medical staff. So this system worked as an actual system.

Here’s that dispensary I’ve been telling you about

Then drugs started going ‘off patent’. This meant that other drug companies were allowed to come along after and use the generic drug that the original drug company had committed 10 to 15 years of research and development to, make their own formulation and sell it. Not having to spend any of that time in R & D, and just having to more or less copy what the first company has done means the new version, or “the generic” can be vastly cheaper! Their version has to be approved by the Australian Government as working in the same way, having the same drug and dosage, and having equivalent efficacy when compared to the original brand, and once this process is complete, the drug gets on the PBS like the original and off we go.

So we got the first batch of second brand names, that were still actually names. Like instead of Noten, we got Tenormin. So now we had two brand names; that was manageable. And then generics went bananas!! They stopped bothering with brand names and just wanted to spruick their company name. So instead of usable names like Noten and Tenormin that were brand names for atenolol, we got drug company names attached to the generic name like APO-atenolol, Terry White-atenolol, Chemmart-atenolol, atenolol-Amneal, atenolol-Sandoz and so on and so forth! You get the never-ending gist. A quick look online tells me that atenolol is available in 15 different brands in Australia.* In America it’s gone much more ridiculous with 143 companies making atenolol generics, and 289 brand names, all slight versions of the one before!!**

How is this relevant to me working in the dispensary? The dispensary is organised by brand name. Then the generic brand comes along and it gets its own slot. Noten is under N, Tenormin is under T. All is well. Then the company name generics come in. Our store has a deal with APO generics so where available we buy the APO generic. But it doesn’t make sense to put every generic in the A for APO section! So the generics get put away by the generic name. Atenolol still ends up in A, but APO-escitalopram goes in E and etc. Except sometimes you go to find APO-hydroxocobalamin and it’s not in H. You ask someone where you might find it and they go straight to N. You ask why, and the answer is: the original brand name was Neo-B12. Yes, that is true, but…”yeah we should move it, we should do that, we’ll do that”. But that was half the point of getting in a few shifts before the real thing, to work out some of these quirks. Another thing: in an effort to be helpful, someone decided that the top 20 most dispensed drugs should be moved out of order to the front of the stands for easy access. Sounds sort of reasonable, but its kind of annoying to go the S and remember, no, its not here, its in the section that I’ve already walked past! But hey, I’ve been able to yammer on about it this much so some of it must have sunk in.

So this shift on Saturday is my first shift “alone” as the “only” pharmacist in the pharmacy; definitely ideal for me. I say those things in talking marks because there will actually be another pharmacist out in the back room working on our supply of medications to 18 nursing homes at all times while I’m out front; another one of the ideal things about this position. So I will never be without a second opinion or some advice or instruction on how to do something that hasn’t cropped up so far, and that sounds great by me! Not that I’ll need it necessarily, but popping out the back to ask someone a quick question is much less full on than having to call the boss on a Saturday!

*http://www.nps.org.au/medicines/heart-blood-and-blood-vessels/beta-blocker-medicines/atenolol

**http://www.medindia.net/drug-price/atenolol.htm