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: 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!