Friday, 9 March 2012

Action Plans

Simple definitions:

Acute illness:
  • Rapid onset
  • Severe symptoms
  • Short course
Chronic illness:
  • Of long duration
  • (often developing slowly or insidiously)
  • Variable severity
Seeing acute and chronic illness separated and delineated makes them seem clearly distinct from one another.

However, in real life, things are often not so simple. Let's take asthma as an example:

I have been diagnosed with asthma since 1988. That is a long time. I would feel comfortable saying that I have chronic asthma. I take lots of different medications to treat my asthma, including daily high-dose oral steroids (Prednisolone). I nebulise medications every day and get daily symptoms of asthma. Again, this is easy. I have severe chronic asthma.

So what about when I have a flare-up of asthma. Sometimes this comes on subtly, making each breath shorter and more difficult over a period of hours or days; sometimes it happens in minutes. This is clearly an acute reaction (especially the rapid reaction, which is often a response to some allergen or other). The acute reaction is easy: I am having an acute flare on a background of chronic asthma. It's less easy to spot the acute exacerbation when it happens less quickly, and it can be very difficult to know where to draw the line between these situations:
  1. I can manage this situation at home by increasing my normal medications
  2. I need to speak to my GP or asthma nurse about extra treatment to keep me at home (e.g. extra steroids or antibiotics)
  3. I need treatment in hospital
The time to decide which situations fit into each of the above treatment plans is NOT when you are having an acute flare. Hypoxia does not help good decision making. For me personally, the desire to stay at home becomes overwhelmingly strong when I'm not well. Hospital, with the undignified gown, endless questions, needle-sticks and bright lights, is not nearly as appealing as my big, soft bed at home.

The best solution to this is to get together with your GP (or consultant, or specialist nurse) and agree a plan. For asthma, you might use peak flow measurement as a guide; for diabetes it might be blood sugar measurements; for gastroparesis, it might be body weight in combination with certain symptoms.

My asthma plan:
  • Peak flow more than 80% of normal: Carry on as normal
  • Peak flow between 50% and 80%: Increase oral and inhaled steroids, use nebuliser as often as four-hourly if necessary; contact GP
  • Peak flow less than 50%: Go to hospital. Go straight to hospital. Do not pass Go. Do not collect £200.
There are other signs that fit into this, that indicate clear deterioration: waking at night more often than usual with coughing/wheezing, inability to talk in complete sentences without needing to take a breath, pulse rate more than 120 per minute (this is a bit iffy, because I have autonomic dysfunction, which messes with my heart rate), shortness of breath at rest, needing to use the nebuliser more often than every three hours. 

Having these signs and symptoms written down in black and white means that the pressure of making a decision is lighter. Without such a plan, I would tend to continue to try all the drugs available to me at home, and wait, and wait, and wait.

I don't want to make a fuss. I don't want them to think that I'm overreacting. I have stuff to do. I don't want to be admitted to the hospital. I'll just try one more nebuliser...

And wait...

Until it's nearly too late, and I end up in the Intensive Care Unit on a ventilator.

Because I didn't want to make a fuss.

I have a chronic illness, which means that I live with daily, constant symptoms, and it can be very easy to become blase about them, even when they become quite severe, as in the case of an acute asthma attack. Having cut-off points agreed in advance with your specialists (GP, consultant, specialist nurses), written down and reviewed regularly, mean that you don't have to make a decision. I'm not making a fuss, I'm just following my action plan.

Action plans save lives.

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