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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Revolt

*WARNING (and spoiler alert): contains self-induced vomiting*

12th April, 2017

From one drama to the next! Honestly! Did I learn nothing from yesterday? The whole phone thing? Nothing about being careful and deliberate in my actions?

See, I have this system. Yeah right! A system is useless unless you stick to the system. Which I mostly do, but mostly isn’t really enough when there’s a system involved. You stick to the system, or you don’t.

This system involves my medications. I’ve probably been over this but I have a nice purple medicine box with 4 rows. One row for my morning tablets, one empty row, one row of 3 valproate tablets for each night still in their original foil because they go smooshy when exposed to air, and the final row for the rest of my night tablets. The valproate for the evening doesn’t fit with the other tablets, hence its own row, but the morning single valproate tablet fits it, hence the empty row. I have carefully marked the morning tablets, and the night tablets so that I can’t get confused. Plus there’s the fact that I unwrap one valproate tablet in the morning and three valproate tablets in the evening. The morning row has red and pink capsules of venlafaxine and 3 little white tablets; the evening row has a dark red iron tablet, a little pink cholesterol reducing tablet, and three chunky quetiapine tablets, apart from the lithium that is in both morning and evening. They are different, the morning and the night tablets; clearly distinguishable. They are not the same. If you take the time to notice, which I periodically don’t! Theoretically, I check all the tablets lying in my palm, to make sure every one is present and accounted for before swallowing them down. I have a list written on the back of the box telling me exactly what should and shouldn’t be there, for reference. But I’ve been on this same combination of tablets for well over 6 months now, and I’m very careful when I pack the box, supposed to be anyway, so sometimes I just pop the tablets and scull them down, get it over with!

Like yesterday. Before I knew what I was doing I had opened 3 valproate tablets, shaken out the dark red and pink tablets, noticed subconsciously the big chunky tablets, and sculled the lot! Even though it should have been obvious that I was taking the wrong tablets: wrong compartment, wrong colours, wrong amount. It took about 20 seconds to get that same shot through the gut as I had yesterday when I realised that I’d lost my phone. I knew then, consciously, that I’d really stuffed this one up!! It has happened before, once I think, but seriously! What was I thinking? And here’s the thing, I wasn’t. I was on auto pilot, distracted and that’s how it all blows up in your face. What’s the big deal? Those 3 valproate tablets, plus the 3 quetiapine tablets, they’s the big deal. They are basically my sleeping tablets, and here I’ve taken them 10 o’clock in the morning! They aren’t actually prescribed for sleeping, they are mood stabilisers but this is their major side effect. Any other day I’d just resign myself to going back to bed and sleeping them off, but not today.

Because there’s something else that I haven’t told you. I’ve got a job!!

I was going to save the excitement for my official start date on 29th April, however this happened, and on the first day that I’m going in to do the official orientation and get all of my paperwork sorted! I have a 4 hour shift starting in an hour and I’ve just taken my sleeping pills by accident/carelessness!! You can see the problem here. First impressions and all that, I don’t want to call in sick for my very first shift; I’m determined to be there and on time and get this job off to a good start. I don’t want to have to go home sick part way through the shift because I can’t keep my eyes open. I definitely don’t want anyone to think I’m under the influence, or unfit for work! That would be extremely unfortunate! Not just for this job, but for my career; the pharmacy board frowns heavily on pharmacists using any substance while on duty, oddly enough. So, what to do? I think you can see where we’re going now.

The ONLY way to try to prevent the sleepy pills doing what sleepy pills do is to get them out of my stomach before they are released from my stomach to my intestines, and absorbed into my bloodstream, making their insidious way to my poor brain. The only way to get them out of my stomach is to induce vomiting!! Honestly, I cannot think of a more revolting, horrifying task to have on ones hands than this. I don’t think I have ever made myself vomit before. I recognise now how compelling a disease bulimia is to convince you that this is a way to live. To me it is extremely repugnant. But what are my options here? It took a lot of psyching myself up for it, and a couple of false starts, don’t ask me how, but we got going. Here’s the killer: I ended up throwing up my entire breakfast which I’d had an hour and a half ago, yet there wasn’t a sign of the tablets and orange juice from 10 minutes ago. Here is the cleverness of your stomach. It knows that its job is to break down food into smaller pieces so that your intestines can do their job. But there’s nothing to break down in fluids, so your stomach lets them right past. In that 10 minute period, my stomach had already released all the fluid/orange juice, and the tablets with it, and they were gone. That whole disgusting, humiliating, distressing episode, for nothing!!

What next? Well, its time to go to work. Fingers crossed that I can handle this and get through what I need to get through.

Here’s the odd things about my sleepy pills. When I first started taking them I would be dead to the world within 30 minutes, or less. Honestly, I would take them and immediately get upstairs to bed because within 10 minutes all of the muscles in my legs would be jelly and I couldn’t step up a stair if I was being chased by an axe wielding madman! My arms would be equally useless. A couple of times I got into bed and then needed to go to the toilet. I would bounce off the wall, my bed, the dresser, my bed, the wardrobe, the bedroom door, the bathroom door and back again! I’m sure it looked completely hilarious from my husband’s point of view but I couldn’t even see straight, let alone have control of my legs. My eyes would go evil vampire red because of how much the medicine dried them out. Basically I was gone for the night. And I got the best sleep! I was drugged out really. And of course as my dose went up the effect continued.

But over time, as the dose has steadied out, I’ve become more tolerant. I don’t get that drugged out feeling now, and I can stay up sometimes for a couple of hours after taking my night tablets. On occasion it does make me drowsy enough to start blinking heavily, struggling a bit to keep my eyes open, but if I really want to I can keep them open; it doesn’t overpower me like it did before. It still helps to give me a good nights sleep, and without it I sleep pretty lightly and spasmodically. As I experienced last night, because after taking my night dose in the morning, I had to take my morning dose of valproate at night to keep the balance, and one tablet isn’t enough to sedate me; plus I had no quetiapine in my system.

So, I took the wrong dose, and didn’t manage to catch it before it got into my system. And now I have to go to work. Well this should be fun! Here’s hoping I can fight the effects for more than a couple of hours.

Okay, next strategy: a large Coke, no ice from Maccas. Hopefully the caffeine will do something!! I drove all the way to work (I was questioning whether that was a great plan, but I felt fine at this stage) feeling okay, until the last 5 minutes when that warm, fuzzy, about to go to bed for the night feeling settled in. I got a little lightheaded on standing, slightly dizzy if I turned my head quickly, and just plain drowsy. My eyes wanted to shut and go to sleep, my thoughts got a bit thicker, I was trying not to speak slower. I hope to goodness I managed to pull off looking as enthusiastic and committed as I wanted to. But there was a big challenge waiting for me. Most of the 4 hour shift involved sitting at a bench reading policies and procedures and signing off on them, and doing orientation quizzes on the computer!! I mean, seriously! Of all the days in the world, I really needed a stimulating day today, and I got reading of less than riveting material!! I think I pulled it off, I mean I got it all done, but I have no way of knowing whether I was doing it way slower than usual, a bit slower than usual, or how many micro sleeps I had sitting there at that bench! Luckily the chair was very uncomfortable so that keep a bit of an edge on my alertness, and after 2 hours when my supervisor went for lunch, I went out and got an iced coffee with plenty of sugar! I think that did help a bit to keep me going for another couple of hours! Plus the fresh air was good.

Yikes!! What a day! But I did survive, somehow, by some miracle, and I’m going back on Tuesday after the Easter break. To be continued.

Did I come home and go straight to bed? Yep, you betcha! A couple of hours sleep did wonders. Usually I can go straight back to sleep at night after an afternoon sleep because of my night tablets so I did struggle a bit getting to, and staying asleep without them. But I didn’t struggle catastrophically. I think I actually had a pretty good night’s sleep in the end, although I was awake from 5am on the dot this morning, Thursday 13th April.

I can’t double up once I’ve taken the tablets, even if they were the wrong tablets. So what’s the plan to get back on track from here? Most of my tablets can only be take once in 24 hours meaning I can’t take night tablets again today. So I’ll take my morning ones tonight, then my morning ones in the morning (the morning doses are smaller so it won’t be such a big deal taking them back to back) and my night ones tomorrow night; then I’ll be back on track. Until then I’m sniffing my head off because of the longer gap in between doses of quetiapine, from morning one day to evening the next. It usually dries me out so sniffing is unusual and annoying! Apart from that, and the obvious drowsiness there shouldn’t be any consequences from stuffing this up, luckily. When you take the same medication all the time, a one off dose mix up doesn’t tend to affect your overall medication levels enough for issues to arise.

And here it is 7am and I’ve written this blog and I’m ready for breakfast, bright and early. I could possibly be very productive without those night tablets, but it wouldn’t be worth it for my mood. Ah the catch 22’s in mental health treatment! 

So, have I learnt my lesson in being more careful? I’d like to hope so, but I find the lesson only lasts as long as my memory of it, and that’s a whole other story!

Avoiding a missed dose

Remember a little while back when I was talking about what happens when I miss a dose of my meds? [Tales of a Missed Dose, 22nd June, 2015]

It’s not a fun experience, and so I go a fair way out of my way to make sure that I avoid it as much as possible! Probably my motivation is just as much to avoid the unpleasantness as it is to keep on my prescribed regimen.

So, how do I do it? How do I manage my medications? What is my system?

strips, tablets, capsules

The strips. This is where the real stuff begins

Is it hard? Yes. Is it worthwhile? Absolutely! Does it get easier? Not so far.

Up until the last few months my medications have been all over the place, add one here, add one there, add one here…that went on for a while! Then the doses were changing and the psychiatrist was fiddling with timing and so on. But lately I’ve had the same meds at the same doses for a while, at least until a week or so ago, so at least I got into a bit of a rhythm with what I’m packing into my tablet box. Although then there’s the thyroxine which must be kept in the fridge, and you can only take 14 days’ worth out at a time. And there’s my lithium dose where I take two tablets every morning, but two and a half tablets on alternate nights with three tablets! That takes some keeping up with!

medication box, dosette

Blank canvas – my weekly medication box exhausted and ready to be repacked

Then there’s valproate which literally cannot be taken out of the foil stripping until you need the dose. I found this out the hard way! The problem arises because I take the lowest strength available which is soluble, and therefore designed to absorb water as fast as possible once exposed. So the first week that I packed valproate into my box, I went to tip out my tablets the next morning and had more-than-soggy valproate! In fact it was more of a glob of paste that smooshed on your fingers and fell everywhere all at once! So I had to fish out all the goopy bits from fourteen small sections of my box and throw out some of my other tablets that had also become soggy and learned my lesson. So NOW, I get out my scissors with my shaky fingers and cut out all the tablets of a ten tablet strip, fold each of the sharp corners of the square into the middle so that it’ll fit into the box compartment, then put it on top of all the other tablets, and try to jam the lid shut. P.S. DO NOT swallow the tablet still wrapped in foil! It has been done, but thankfully so far not by me. I think the sharp edges would give me the hint well before it got as far as my throat; or so I hope!

Epilim

So Valproate, I cut the strip into 10 squares, then fold the squares until they fit into the medication box with the other pills

But you’re a pharmacist, it’s probably easy for you?

I’m a pharmacist second, but a patient first. My systems and medication knowledge is invaluable in understanding my condition and sorting out my meds! In fact, I constantly wonder how people without that knowledge get by at all!! I say that because at times I feel like I’m barely keeping it together: what scripts do I need when I see the doctor (among all the other things I need to talk to him about!), what scripts do I have to take to the pharmacy to get dispensed this week, and when will I get there? What tablets are in low supply, do I have a current script for that? Have I got enough thyroxine downstairs in the fridge, an inconvenience to my medication box packing that the company did not consider strongly enough when developing their product?! Have I taken today’s tablets? Did I take the right time, like did I take the morning tablets in the morning or did I not look closely enough and accidentally take the sedating night time doses in the morning? Did I remember that I must not have fizzy drinks within two hours of taking valproate because it will dissolve much more quickly and make me drowsy? Loads of questions and loads of answers, and it’s still tricky matching them up properly!!

The many faces of scripts, handwritten, computer generated and the pharmacy yellow slip. And yes, my doctors have terrible handwriting!

The many faces of scripts, handwritten, computer generated and the pharmacy yellow slip. And yes, my doctors have terrible handwriting!

So here are my many systems.

A very short time into my Prep year, my teacher commented that I’d lose my head if it wasn’t screwed on! This wasn’t prophesy or prediction of how my life would turn out, but simply a comment on how I was then. I was only 5, but I remember it clearly. It was a kind of epiphany moment. She didn’t mean it maliciously, but it was a pretty apt saying at the time, and for quite a few years to come!

Being organised probably comes from my Dad’s side. Every week he would strip back his tradie van to the bare essentials, remove all the Coke bottles and get it stocked, clean and ready to go again. Of course a lot of his motivation was listening to a footy match on the radio on his own without noisy kids! He would come home at night and the messy house was a constant trial to his patience!! He would get up a head of steam and do a week’s worth of chores before dinner! We all just vanished into the paint work and let him get it done; making any kind of noise meant you might get a faceful of steam!! When I was in primary school, he taught me how to pack for a holiday systematically, starting from the feet and working all the way up to make sure you don’t miss anything. Shoes, socks, tights, skirts, tops, dresses, hair ties, hats etc. I used this for packing, but the rest of my life was less designed and more accidental. Rushing from place to place having too many things to physically fit into the hours of the day and accidents happening all over the place! That came from my mum. Surprisingly, since my mum’s mum is uber organized. Forgot my lunch, forgot my jumper, left my USB with my presentation at home, missed a deadline etc! None of this really taught me the life lesson you would think it should!

boxes, bottles, tablets, capsules

The real deal, all of my many tablet boxes and one bottle…and there’s one box in the fridge

Studying pharmacy was a revelation to me, and it really has gradually changed my approach to life. So has the last 12 years with my now-husband, who is very systematic and had taught me a lot about being organised. Pharmacists have to be so systematic that there is almost no possible way that an error can occur. Each of us has to work out our own system that doesn’t fail when curveballs come out of nowhere, but is a failsafe as much as possible. I’m not going to go through that because its tedious from the outside, but next time you’re waiting in a pharmacy, and they’ve told you the script is going to be 10 minutes even though that’s not possible, and you’re wondering what they’re doing, distract yourself wondering how that pharmacist is ensuring your health and safety.

pink bag, surprise, treat

Bag of medications disguised as something pink and desirable! Cunning

So my medication taking has become a system. It didn’t start that way, because at the start I was on one antidepressant. That doesn’t take a lot of managing apart from remembering to take it! Then I was on two antidepressants, one in the morning and one at night. That took a bit more remembering. Then the pivotal moment when I was diagnosed with bipolar and started on a mood stabilizer, and another one, and another one. It got too much to keep in my brain, so I took the old person option and got myself a medication box so that I could make up a week’s worth of pills at a time, and stay ahead of the game, instead of waking up in the morning to get ready for work, and finding I didn’t have any more of a tablet! Having to squeeze a trip to the pharmacy into my already tight getting-to-work schedule was essential, but stress-inducing!

medication box

Nearly done, got to visit the fridge and fold the silver squares

I have an up-to-date medication list that I’ve written on the back of the box, and that I keep a copy of in my handbag, and a copy of in the NPS Medicines app on my phone, and which I update after every doctor’s visit if any medication changes have happened. This is vital. If anything ever happens, the first thing your hospital pharmacist will ask for is your medication list. Having it up to date means increased safety for you. That’s the most important thing. We don’t want to give you something that will make you worse by allergic reaction or by interaction with your current meds or your medical conditions.

medication list

The ‘official’ medication list, updated every doctor’s visit…maybe I should type it out to make it look less made up!

Every week when there are only a couple of doses left in my box, I repack it according to my list. I cross check each tablet as I pack it, i.e. I take venlafaxine 450mg, which is 3 capsules of 150mg, so I check the list and pop out that many tablets. It sounds so easy, but an error right there could be catastrophic. Cross checking makes sure every prescribed medication ends up in the box, in the correct amount, at the correct time of day, every day. So I sit up on my bed and surround myself with boxes and strips and bottles, my list and my box. It’s actually a satisfying job, ticking each med off one by one and ending up with a neat and tidy box of lifesaving pills. I end up with a massive pile of rubbish, mostly in the form of popped out strips. Pharmacy isn’t exactly a green industry; the medications demand certain wrappings and changing that order would be unsafe.

medication box

Ready to go! Time to concentrate, accidents do happen but good idea if they don’t!

Unfortunately the names of the days have rubbed off the box and remembering the order wasn’t working so I had to relabel the medication spots. I ended up writing AM or PM as well, because a couple of times I’ve taken the morning medications at night and ended up not sleeping for hours, or taken the night meds in the morning and been doped out all day! That was because I started checking on autopilot and not really checking. So now reading the label of the dose reminds me, hopefully, whether I’m meant to take that dose or not.

System change #71! Always updating and changing to improve my safety

System change #71! Always updating and changing to improve my safety

Forgetting is a big part of my life now. I start a story and can’t remember why I was telling it, I can never remember names, I forget a conversation from earlier that day, and many other things. Pity help me if I get to 80!! My husband will have gone mad by then! So I have alarms. I’ve always done this since I only had one med. First it was an alarm that you switched off. Then I’d forget all the same. So I changed my alarm to being able to be snoozed three times. I’d snooze it three times, and forget! Procrastination much?? So I found the NPS (National Prescribing Service) excellent Medicines app and put some alerts in there for the morning and night. These can be snoozed endlessly so I know that it won’t let me forget!

reminders, alarms

The cool app from the good folks at the National Prescribing Service – recommended!

When it’s time for my tablets, I go to the box and look for the day and the time. I tip out all the tablets, and take the foil off the valproate. I count the tablets against the mental dose list, or actual dose list if I can juggle the tablets in one hand and box in another. I check that each tablet for that time of day is there, and in the right dose then scull them! My husband hates this, he thinks that I should take them one at a time, but that would take forever! I’d rather just get them down as quick as possible.

20150520_093805

I’ve developed a new system now. My alarms go off at 8.30am and 8pm. I’m meant to take my tablets when the alarm goes off, but however systematic I am I’m still a procrastinator. I know that my tablets are keeping me in the good life, and that without them I’d be in all kinds of awful, but there’s still that little part of me that doesn’t want the tablets, because it doesn’t want the illness! A small part of me that has the hopeful thought that maybe if I don’t take them everything will just go away. Of course that’s ridiculous! But it’s just how it is. So I snooze, and snooze, and snooze. Ridiculous and childish but there you have it! I can’t imagine how much more difficult it must be for people who don’t acknowledge their illness, are in denial, believe the medications are evil or unnecessary or poison, or are being medicated against their will.

My husband does a good job of asking me if I’ve taken my tablets, but my memory is absurd and I remember taking my morning tablets and say yes I’ve taken my night tablets. A couple of times I said yes yes, and I hadn’t taken them. So now, once I’ve taken them, the lid stays up, I don’t clip it down again, and so both of us at a glance can tell if I’ve taken them or not, no confusion.

Some are empty, some are closed and it helps me keep track and avoid slip ups

Some are empty, some are closed and it helps me keep track and avoid slip ups

Well that’s about all my systems. I try to avoid anything that relies on memory, and try to have a clear, repeatable, systematic way of keeping well. At the end of the day, its fingers crossed and trust in all the steps that have been taken to take care of me.

Hope you enjoy the pretty pictures!