Wednesday, July 29, 2009

When you're sliding into first...

There are often times when the chief complaint truly misses the nuance of what the real concern holds in store.

For instance, a chief complaint of diarrhea in a child is not so common, not so nuanced, not so big of a deal.  

(As an aside, newFNP had a pediatrics professor who invariably pronounced the word diarrhear, which so brought glee to newFNP and BostonFNP during a long day of dry lectures-- and it still does to this day!)

But what if diarrhea is not just diarrhea?  What if it is encopresis?  Well then, you're in for a hell of a different appointment.  

The history went something like this: the six year old boy was toilet trained, but then he started soiling.  When he's with mom, she has him wear diapers, even to school.  When he's with dad, he is instructed to go commando so that he is forced to "learn to control himself."  Both interventions wholly unacceptable and antithetical to appropriate treatment.  

To be fair, this is in part the clinic's fault.  He had been seen twice before for the same problem, had received minimal guidance and had no improvement in symptoms.  No big surprise there.  It's a confusing diagnosis for parents.  It's tough for primary care providers to give diagnoses such as this the appropriate care given that it involves greater than 10-15 minutes, education from the provider and counseling from an actual counselor.  

What makes this even more difficult is when the kid's father is intoxicated in the exam room and when the kid's mom is absent - both from the appointment and largely from his home life as she works and spends an extraordinary amount of time volunteering at church.  It was clear to newFNP that the kid was used to his dad being drunk when she watched him call his name and gently slap his face in order to rouse him when she called them in from the waiting room.

All throughout the encounter, newFNP was concerned about neglect.  But the kid was clean, he was growing appropriately, and he related well with newFNP and with his father.    His future might not be the brightest given the family history of alcoholism and the poverty, but poor alcoholics raise healthy thriving kids so we'll have to institute a prospective study to see where this kid goes.  NewFNP decided that it wasn't neglect - that it was ignorance regarding the problem and lack of support.

NewFNP gave the appropriate education, both verbally and in written form, instructed the father that both the diapers and the sans undies must stop A.S.A.F.P., ordered an x-ray, prescribed Miralax and toilet times, and hooked the family up with free counseling.  This took about 40 minutes.  

Worth it.  They showed up to their counseling appointment the next day and have follow-up scheduled.  

Saturday, July 11, 2009


NewFNP is back from the most restful time she ever had in the state where she attended graduate school.  Her school years there were full of studying and bad weather and really bad weather, whereas her Independence Day long weekend was full of tranquility, mild weather and relaxation with grad school pals.  

And now she's back and has questioned more than once why on earth she lives in the urban jungle when tranquility and waterfalls are available to her??  Ah yes, proximity to Barney's.

Her first day back in clinic was also her first day with her second ever student from her alma mater.  It was a day filled with tough patients.

There was the 2-month old infant who would not make eye contact.  Is it a retinopathy? Is it an early indicator of autism?  NewFNP isn't sure.  Ophthalmology consult!  

Then there was the Mirena that twice fired prematurely with no assistance form newFNP.  NewFNP felt like a nervous lover - and in front of a student!  Eek.  Her student later asked newFNP if that was a normal amount of nervousness for an IUD insertion, to which newFNP replied, "For newFNP or for the patient??"

Then there was the 20-year old G1P0 who was far more interested in picking at her thick French tips than participating in her prenatal care.  

And finally there was the 19-year old G1P0 with a BMI of 55.5.  No joke.  She is 5-foot-1 and 294 pounds at 36 weeks gestation.  She was 254 at her first prenatal visit.  

NewFNP frequently reads lay articles and medical journals with stories and studies and statistics about the obesity epidemic.  Fourteen is the new ten.  Children are at risk.  This will be the first generation to die earlier than previous generations because of the effects of obesity.  The south is fat.  

OK.  NewFNP gets it - as a nation, we're fucking fat.  

But please, please.  Tell me just what in the world providers are to do?  These are the avenues newFNP has attempted with her portly nullip

1) just the facts, ma'am (health of mom and baby, labor complications, gestational diabetes risk); 
2) supportive listening and encouragement (yes, it's hard to change our habits but you're doing this for your baby and yourself; yes life has dealt you a rotten hand -- let's change that for you and your baby!!);
3) stern lecturer (this has to stop -  we are talking about the health of you and your child);
4) Richard Simmons (have you tried our prenatal yoga class??);
5) throwing the fruit punch in the trash.

And this is with one patient. 

Obesity is a public health problem.  This is not a problem that individual providers can address on a large enough scale to prevent and treat obesity.  It's not that newFNP doesn't talk to her patients about their weight - she does.  She talks to normal weight patients, underweight patients -- all 3 of them, and overweight patients about their weight.  But that isn't enough.

Children are fed trash in public schools.  WIC -- for all its great work -- gives away coupons for trashy foods.  Parents give in to children's pleas for junk food.  Poor urban areas are full of fast food options and liquor stores.  Poor urban areas are not safe for outdoor play and exercise.  Fruits and vegetables are expensive.  

So what are we going to do?   NewFNP is open to suggestions.  


Congratulations and love to BostonFNP and BostonJD.