Soda - two thumbs down

NewFNP was at the gym yesterday, reading the NYT whilst stationery biking. It's not her favorite workout, but yesterday was a day during which newFNP had to kill two birds with one stone. Thus, NYT and exercise together -- it's like church for newFNP.

The Week in Review section had a below-the-fold article about taxing soda written by Mark Bittman, whose bread recipes tend to be quite good, but whose sugar cookie recipe leaves something to be desired. Clearly, no manufacturer of any product is supportive of a tax on their wares, especially to the tune of 1 cent per ounce and when your product is being blamed as a component (and not an insignificant one) of the obesity epidemic. The industry quotes against such a tax were so transparently douchey, especially the one from one Mr. Derek Yach of PepsiCo who wondered if a tax on sugary food might make things worse by leading to an increased consumption of fat.

It should come as no surprise that newFNP supports such a tax. (She supports taxes on cigarettes as well. If marijuana were to become legalized, she would support a weed tax.) Soda has no nutritional benefits. Okay, okay, it has sugar. But overall, while tasting good, it is a piece of dump nutritionally speaking. When newFNP counsels newly diagnosed diabetics - something she does with alarming frequency - one of the first points she makes is that soda is a no-go, a killer, absolutely a never on the diabetic food pyramid. She believes that using the public health model that targeted cigarette consumption is a reasonable approach. After all, cigarette consumption has decreased significantly over the past few decades.

The article got newFNP thinking that there are other ways to decrease soda consumption. In newFNP's clinic, many, many of her patients receive food stamps. A quick trip to the national food stamp program website states quite clearly that the goal of the program is to help low-income families buy food that supports good health. Clearly, soda should not be on that list. Food stamps are a government program and the government already dictates some exclusions from the food eligibility list. For instance, alcohol is excluded, yet non-alcoholic mixers are not. Cigarettes are excluded. Flaxseed oil is excluded, yet cooking wine is okay. Hell, you can get bows and arrows with food stamps if you are lucky enough to live in Alaska!

If newFNP were asked to update the eligibility list, she would exclude all non-dairy sugary beverages. Good-bye Sunny D! You're not fooling anyone! See you later Orange Crush, you asshole. No one needs you! And no one would be about to do the Dew with food stamps.

But newFNP wouldn't stop there. No Hot Cheetos or any kind of chips. Knowing that food stamps and health are political issues, she might compromise and let Sun Chips or Baked Lays sneak by. No candy. No sugary cereals. No Lunchables. No Hostess, not even the delicious chocolate doughnuts that are so yummy on roadtrips home from snowboarding.

Yes, nutritious foods are expensive. Fresh fruits and veggies go bad if not eaten in a timely fashion. But frozen veggies don't. And if one's cart isn't piled high with a bunch of shit, the food stamps might go a little farther and actually work toward the program's goal of supporting healthy nutrition options in poor families.

And then move on to the schools. No soda dispensers and quit cutting recess and P.E. time. Seriously people - don't just have kids run the mile. Throw a kid a bone and help them to find a physical activity that they like, that they'll do for their entire lives. How about mat pilates P.E.? Hip hop dance P.E. class? Weight training. Not square dancing. Repeat - not square dancing.

Michelle Obama, if you're reading this, newFNP is here to help.

Fat

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.  

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Congratulations and love to BostonFNP and BostonJD.

Oink

Gone are newFNP's mojitos and walks along the malecon.  She is now back in the thick of it but very thrilled to have a new referral source to help out her patients.

NewFNP's clinic is very lucky to have our nutritionist, Red.  She is not to be confused with the pirate nutritionist, who must be swashbuckling with some bonny lasses as she has been nowhere to be seen.  No, Red has been a presence three days a week and thankfully so!

NewFNP had a sweet patient this week who wants to get pregnant.  Super!  Only it's not so super that she is over 350 pounds and has her periods 2-3 times per year.  NewFNP did some general education, gave her some folic acid and sent her to Red for a more thorough intervention.

Later, newFNP perused Red's note to see what, in fact, nutritionists talk about in their sessions, where they chart, etc.  What newFNP found was astonishing!

Those in the know are familiar with the SOAP note that providers use to describe the clinic visit: subjective history and complaint, objective findings, assessment and plan.  Learn it, live it, love it.  

Well, nutritionists apparently have their own format.  It goes a little something like this: problem, intervention, goal.  

PIG.  

The frigging nutritionists use PIG!  What the fuck?  That is so wrong.  So, so wrong.  Has no nutritionist ever stopped to think of the cruel irony?

PIG.  Seriously people, what the fuck.

Downtown Cocoa Brown

NewFNP has rarely, if ever, found herself in the position of requiring - let alone desiring - a friend's presence while at the doctor. Truth be told, she would rather keep that part of her life private. Especially as it relates to her lady business. Good news? Great! Bad news? Private!

However, if newFNP's patients want to drag their sisters/friends/cousins to their appointments, who is newFNP to deny them? Of course, newFNP asks family members to exit the room during sensitive histories or exams, but respects it if her patients want to use the buddy system.

This morning, when newFNP read the chief complaint of "boil on her vagina," she felt a little glee at the thought of incising and draining what she assumed to be an abscess. It's been a long time since newFNP performed any mini-surgery and, frankly, she's been missing it.

Alas, it was not to be.

NewFNP received permission to make this a group visit and proceeded to ask her patient who, by the way, had a BMI of 41, how she could be of help. Her friend, whose BMI was easily 50-plus, piped up with, "She got a boil on her cocoa brown!"

NewFNP elicited the pertinent history and got the patient into the lithotomy position - no easy task - and began to survey the region when her friend came around to get a lay of the land as well. NewFNP quickly maneuvered the makeshift drape in order to cover her patient.

"Whoa, whoa, whoa," newFNP said. "Is it okay with you if she looks?" NewFNP's patient, astoundingly, gave her the go ahead and her friend jumped on in.

Again, newFNP would prefer that all of her friends would just stay the hell out of her own cocoa brown. Permission to view the pelvic exam denied!

This lady's cocoa brown wasn't exactly rocking the cocoa puff, per se, but more of the cocoa herpes. When newFNP asked her if she had a new partner, she answered in the affirmative. After determining that this was a male partner, she asked if he was a good guy. Her friend emphatically answered that he was, in fact, not. To which, newFNP's patient informed the room that she would no longer be "fucking with him."

Good then. NewFNP provided some safer sex counseling, offered further STI screening, and bid these two fine ladies adieu.

Exam room 6, ready for seating

NewFNP hasn't commented on obesity lately, but she cared for a patient who got her thinking. This patient has a BMI over 60. Although newFNP is no Mavis Beacon, BMI >60 is no typo. This patient came in for various complaints, including abdominal pain. Let's just call newFNP's exam "limited by habitus."

This patient also noted lesions in her skin folds. NewFNP has treated fungal intertrigo in this patient before, but has not seen her in well over a year. Perhaps if she would have, newFNP might have stopped the awful maceration to this patient's thighs, pannus and buttocks. NewFNP hasn't been doing weights lately and it showed as her arm was shaking in an effort to hold back the pannus in order to examine the extent of the damage.

And can newFNP say it once again, ladies? If your BMI is over 60, your lady parts are also going to be fat. And when those lady parts get fat, the picture is oh-so not pretty. And when you have macerated abdominal, thigh and groin-adjacent skin, it is, quite frankly, time to hang up the bikini underpants and find peace with the big cotton grandma bloomers.

Seriously.

But what really struck newFNP is how demoralizing it must be for this patient to come to the clinic, to have newFNP struggle to hold back her obese belly and to have newFNP counsel her on the merits of the grandma panty. How she must feel some amount of shame every day regarding her weight. How every activity must be a struggle for her. As horrifying as the physical effects of obesity are, the emotional effects must be comparably devastating. NewFNP felt a combination of honor and horror when this patient asked her if she would do her pap. On the one hand, she must have felt respected and cared for by newFNP. On the other hand, that is going to be one hell of a pelvic exam.

**********

When newFNP was in public health school, she had this frigging awful narcissistic professor who informed the students about her success as a physician, model, poet and basketball player, ad nauseam. She also took away our break, probably because she knew that we would talk vicious shit about her, not only to read us her crappy poetry, but also to make us exercise. We hated her for it. This was, after all, public health school. The majority of us had already had our morning workouts before we came to her piece of shit class. NewFNP isn't saying that she is going to adopt this as a practice, but that she must admit that she has considered finding a far less offensive way to encourage physical activity in the waiting room. After all, the patients may be sitting there for hours.

Perhaps newFNP's clinic should buy buzzers a la Cheesecake Factory. The patients can then go exercise and we can buzz them when their exam room is available!

A Cure for the Obesity Epidemic

I've got it. It's a plan that will never come to fruition, but one I think has the potential to be quite effective. No, it's not the removal of sodas and Taco Bell, Golden Arches,Burger King and vending machines from schools. It's not more exercise or daily P.E. in schools. It's not 'you'll get Type 2 diabetes and have hypertension and dyslipidemia, all predisposing you to a big old MI.' Those are good ideas, by the way, great ideas even, but my proposed campaign is meant to have a visceral response, striking at the very core of insecurities all over the world.

(I love hyperbole.)

It's fair to say that all people have some degree of interest in their genitals, right? I mean, we have penis pumps, Brazilian waxes thanks to those evil J Sisters, circumcision, female circumcision as well as various nether-region accoutrement. Men can't stop touching their goods from infanthood until, well, until they die I guess. This obsession is the basis for my campaign.

My idea is this: let's raise the awareness of the 'hidden penis' and the 'fat vagina.'

I mean, does any guy want to exchange his average penis for a huge pannus? It's not even a fair trade!

And ladies have labiaplasty in order to have a perfect genital portrait. Not my patients, but I've seen the advertisements and if plastic surgeons can play off vag insecurity, then so can public health. So don't get a huge vag!

And after this awareness raising campaign, we can transition back to the more traditional interventions. It's worth a shot. The other methods sure as hell aren't working very well.

Rant

NewFNP is tired today. When newFNP is tired, newFNP is pissy and easily frustrated. It's a familiar rant - the one I am about to share - but a rant I continue to feel the need to express nontheless.

If you are nearly 300 pounds, with a BP of 191/106 and a glucose of 425, don't fucking tell me that you are on motherfucking Jenny Craig or Weight Watchers or that you are Sweating to the Oldies. Just tell me that you had a Double Western Bacon Cheeseburger for breakfast and that you might just have a repeat for lunch, extra mayo and a large fries. Do not blow sunshine up newFNP's ass, especially sleepy newFNP. Because newFNP will hate you.

Part of the problem with being newFNP is that, as newFNP, you like to get straight A's & maybe one B in some bullshit class. Well, when you are my uncontrolled diabetic and hypertensive patient, I get an F. And it's your fault. Like a group project gone woefully awry.

I'm willing to work with you and even carry the burden of our group endeavor. But don't piss on my head and tell me it's raining. Oh, My Lady of Uncontrolled Chronic Disease, why must you torture me? You are too young for nephropathy and LVH, and you understand me because we speak in English. Yet you do not heed my sage advice.

And newFNP stayed up too late last night to be empathic newFNP to all patients today. That is a burden of the role. One must be on one's game, even when one is a crabapple. Therefore, newFNP must now toddle off to bed so as to be stellar tomorrow.

Because that patient is coming back. Balls!

A Tale of Two Fat Ladies

The tale has almost nothing to do with fat, although both of the ladies around whom the tales revolve were in the mid-300 pound range. No, these tales are far more interesting to newFNP than fat.

Tale One:

How many times can one person consume antibiotics for an ulceration caused by moist flesh rubbing on its neighboring moist flesh? The answer: a shitload.

My patient has had an ulceration on her left breast for years. It comes and goes, it's purulent then not, it has been the target of antibiotic treatment time and time again, none of which at the hands of newFNP. As newFNP has stated time and time again, she is a tight-ass with antibiotics. Rather than empirically treat and given her ongoing love/hate affair with Amox and Keflex, newFNP cultured said ulceration and sent it off to the lab. Bye bye culture!

Imagine my surprise today when, in the midst of 17 patients seen in the morning session, I see a lab result screaming 'MRSA' sitting on my desk. No wonder the 2-year course of antibiotics didn't knock that sucker out.

Aside: newFNP had never actually recommended a bra as a component of treatment for a patient until I saw that those pendulous breasts, each bigger than my head, were resting unsupported on the patient's ample abdomen. Rx: BRA!!!

Tale Two:

Religion is important to many of my patients. NewFNP tends to keep any spirituality, or lack thereof, to herself but listens respectfully when patients share their faith. NewFNP has even been known to encourage spiritual counsel in times of distress.

My kind and compassionate patient today has relied upon her faith to support her during a difficult transition from married to separated. Her faith is so important to her that she brought a photocopied reading to drink in during her lengthy wait at the clinic. All in all, a smart move.

As I was examining her, she placed the readings on the exam table behind her. During her lung exam, I glanced down and noticed the word 'Jews' in the selection. During a seemingly thorough, entirely benign and incredibly distracted exam, I came to learn that her religion teaches its followers that the Jews are indeed responsible for killing Jesus Christ. I was frustrated and saddened, yet said nothing. What is there to say?

This just in....

There are few things that newFNP likes to ponder less than pelvic floor disorders and urinary incontinence. I was, however, at a conference recently and found myself desperately and vigorously performing Kegel after Kegel in order to stave off a sad, sad future. In fact, I'm doing my Kegels now and you should be too. We should all have the lactic acid build-up normally associated with leg presses, 10-mile runs and push-ups. Because, baby, I do not want my uterus heading south for the winter. Nor am I relishing the thought a future with rubber mattress pads.

The reason I am exercising my vagina 100 times more than my abs or glutes is that the keynote speaker at the conference presented data from the WHI that stated that a full forty-frigging-one percent of women had some form of prolapse. Hey, maybe your bladder is just sneaking posteriorly into your vag, but maybe your cervix is at your knees. I don't want either. Kegel, Kegel, Kegel... feel the burn.

Sure, childbirth makes a difference in the likelihood of anatomical slippage, but guess what? It's the first kid that makes the most difference and, I hate to say it, but nulliparous women may share the prolapse experience with their more fertile sisters. Thinking of scheduling a c-section like your gal-pal Britney S.? Well, that's not gonna save you either. So go ahead and have your babies in whichever way you choose, but Kegel it up, ladies. And do your best to lose the pregnancy weight, because overweight (waist circumference >88cm) isn't going to help matters.

The same goes for incontinence. Parity, obesity, hysterectomy... they all will have you running to bathroom, stifling your laughs and hoping that your little cough goes away quickly. Apparently, 50% of us will have incontinence. Son of a bitch, does that ever suck. Kegels. 30-35 exercises per day. I don't want vaginal hypertrophy, but I'm thinking the more, the merrier when it comes to incontinence prevention.

Diabetes also plays a role in incontinence due to the nerve damage. So, let's see what sucks about uncontrolled diabetes. It's not the death so much, in my opinion, as all the horrible effects of the disease. Blindness, kidney dysfunction, erectile dysfunction, amputations, thick toenails, heart disease and incontinence. None of those are my idea of a good time.

In other news, updated CDC guidlelines, due to come out next year, state that we should no longer be prescribing 2g of Flagyl PO for BV. It's just not efficacious. It's all about the 500mg PO BID x 7, 5 nights of Metro-Gel or 7 nights of Clindamycin cream. So give your ladies a break and treat their BV effectively, OK?

A case and more

After 4 days of work, newFNP is flat out exhausted. Is it 4 days of waking up at 6AM? It is 4 days of thinking in Spanish? Perhaps 4 days of a pace to which newFNP is utterly unaccustomed? Let's chalk it up to a combination of the three. To say that newFNP spent her first day off energized and ready to take on more would be a big fat lie. To say that it is a miracle that she went to the gym, cleaned her bathroom and have started to conquer her laundry is not hyperbole. She's ready for another nap.

So newFNP saw a woman yesterday with a history of mild RUQ tenderness and slight AST/ALT elevation. She is obese and the provider before newFNP was unable to palpate her liver. Ditto for me. The previous provider ordered an acute hepatitis profile - negative for A,B, & C. No statins, tylenol or alcohol. No history of gallbladder ("vesicula") disease in the family. What does one so when your differentials are exhausted (to speak nothing of your own energy level)? Well, if you are new FNP, you ask the MD and she says, "Is she fat?"

"Yes."

"Hypertriglyceridemia. Tell her that this is as serious as hepatitis and she must change her diet. Check her lipids."

OK! Done.

But this brings newFNP to another point. Every fat patient she sees - and these patients are unfortunately not infrequent - reports a very healthful diet, rich in fruits and vegetables with rare intake of fatty, high-calorie foods. Do they eat ice cream? They say no. Sure, they have uncontrolled Type 2 diabetes, but according to their diet recall, they should all be lollipops. Now, newFNP is not one to throw stones, but come on. What is in these vegetables that makes all of her patients fat? Are they fat-enriched vegetables? That is a genetically modified food newFNP has not yet heard of. Are they cooking their foods in lard, oil, butter? They say no. NewFNP calls bullshit, but that is not a therapeutic tool she wants to bring into the clinical encounter.

NewFNP knows what she should do. Have them write down everything they are eating for three days and bring that back to me. Give them a list of culturally competent healthful choices. She has done neither. Shame on newFNP. It's on her to do list to remember every frigging thing she should do, but you have to crawl before you can walk. She's scooting.

If you are in school and will be working in a clinic in which you see pediatrics, learn the vaccination schedule. NewFNP bitched so much about learning it when there is a chart in every clinic listing them. It's true, her clinic has a chart, but you need to have a working knowledge of it. NewFNP almost let a kid leave yesterday without his 11-year old Td. Ugh! She's not an idiot, but she is an overwhelmed new provider. And he was my last patient of the day.

OK, she's an idiot. But she won't be the next time.