National NP Week is Not a Box of Chocolates

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November 9th-14th is National NP Week.  No this is not supposed to be a Hallmark holiday filled with chocolates, free lunches and thank you cards. That’s for Secretary’s or Bosses Day (which I think is bogus but that’s fodder for another post).

NP week was designed to be an Awareness Campaign to help educate the public about NPs, and to remind lawmakers of the importance of removing outdated barriers. This year is especially momental as it marks the passing of the NYS  Modernization Act: Effective Jan 1, 2015,  this new law removes the requirement of a written practice agreement between an experienced nurse practitioner and a collaborating physician as a condition of practice.

what's it like?

The one thing I was completely sure of when I began my career as a Nurse Practitoner was how much I didn’t know. The classroom time, credit hours, and clinical experiences satisfied my state’s requirement for NP licensure and national certification, but it would be a long while before I would be comfortable in my “new shoes”.

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Preventative care, acute and chronic illnesses, childhood ailments, common health problems, medical mysteries, and terminal disease were to me a murky land and I was a pilgrim. When I began this adventure twenty-three years ago, there was no Epocrates, UpToDate, or other Medical Apps to sift through differentials and no google images to help identify rashes.  It was just me and my Hoole, and a collaborating physician who had faith in me.

My hands shook when I wrote a prescription. My heart pounded when I heard the complaint “chest pain”.  How could I do this? I wanted to run, throw my lab coat in the dumpster, and find a job at a coffee shop. I could do that, make a good cup of coffee.

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A year passed, things started becoming easier, and I grew in confidence. Year two, I no longer felt like an alien, I had gained experience. The fog of greenness had lifted. I had become a Nurse Practitioner.

Now it’s two decades later and National NP week.  I almost forgot about it, again! Then I saw a shout-out email sent to my department with me and fifty of my colleagues listed. It read,

National Nurse Practitioner Week. Please join me in celebrating the many accomplishments of the Nurse Practitioners, Clinical Nurse Specialists, and Physician Assistants in our Department. Their expertise, commitment, and team spirit are often the wind beneath our wings.

Despite the fact that last sentence starts Bette Midler singing in my head, that was gracious, and sufficient.  I don’t need candy, or to be taken out to lunch. This week is not about recognition, it’s about awareness. There are many misconceptions about who we are and what we do. NP’s are not MD’s. We have similarities, we are different.  We are not a replacement for doctors, rather we are a branch of the same tree: health care providers.

NP,  MD, DO, PA, CNS, CNM, CRNA, RN: Our Health Care Rock Stars  who do life saving, life-changing , ground-breaking, rad work. I applaud them all!

Being a nurse practitioner is not easy work. I think only another NP can appreciate what I mean by that. I don’t work in a posh office with Stickley furniture and catered lunches. No banker’s hours for me.  I have a ten-minute walk from my parking space to the hospital entrance. And when I greet my first patient,  it’s game on.  From the first to the last it’s all about them, not me. I listen, support, hold a hand, give a hug, look in eyes, encourage, reflect, help, guide, teach, smile and do what I can, with what I have, where I am.  And when I’m extra tired or feeling worn and thinking,  I need to retire , a patient will say something to snap me back to why I love my job.

“Thank you.  Can you always take care of me? You don’t know how much this means to me. You’re the first person that didn’t treat me like an addict.  Yes, I think this might work! I’m so glad you’re still here. You are good at what you do. I appreciate your kindness.”

Now that’s recognition. Hearing those words keeps me coming back. I chose this career, if I could go back in time I would choose it again in a heartbeat.  Kudos to my fellow NP’s and let’s not worry about whether or not we get a card, a latté, chocolate, or a thank you email. That’s for Hallmark fluff holidays. National NP week is about education and awareness.

All about NP’s: Downloadable Infographic

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If I Told You the Truth You Would Think I’m a Horrible Person

P1140783 Are you smoking? Do you do drugs? How much do you drink? Are you having sex? Is someone abusing you? Do you have thoughts of harming or killing yourself? Are you having an affair? Did you steal this? Did you cheat? What’s wrong?

Providers, parents, spouses, therapists, teachers, caring friends ask difficult questions like these. But the truth – the carefully hidden secretsare not easily disclosed.

Why?

Because.
If I told you the truth

If you knew what I did, what I am doing, what I really think.
I can’t tell you.  I can’t tell anyone.

I Can't Tell You Because
I Can’t Tell You Because

We need to build trust to gain truth.
When discussing delicate subjects or asking uncomfortable questions, keep in mind what is said is not always the whole truth.

The most important thing in communication is to hear what is not being said.  Peter E. Drucker

When taking a history I’ve learned to double the alcohol and cigarettes patients admit to. Out of breath, gum chewing, coughing, clothes smell like smoke tells me my patient is smoking despite her claims to have quit.

Impossible is always probable. Pregnancy tests come back positive despite emphatic insistence there was no possible chance.
I would never do that means I’ve already, I am currently, or I’m thinking of it.

People tell you what they think you want to hear. They don’t want to disappoint you. They don’t want to disappoint themselves. They don’t want you to think they are horrible.
Deny, lie, pretend, avoid, hide, bury, run, evade, fight.
P1150490 What do we do? How do we encourage honesty? How do we gain the trust of those we love or want to help?
Furthermore, wherever we find ourselves in life, how can we help others achieve their goals?

Of all the techniques I’ve tried to help me build trust to gain truth, the only thing I’ve found that works is to be genuine. To be real. To be me.
To show my vulnerability, my humanity, to accept others where they are, for who they are, and show them they don’t have to settle, they can change, there is hope, they are not alone.  We all have baggage, doubts, sins, and scars.

Tell your teen you are not there to judge, lecture, scare, or shame.
P1150503Reassure your client you are there to identify problems, accurately diagnose, propose proper treatment, and provide needed follow-up. If they are honest, you can better help.

Take an interest in a neighbor, your co-worker. Say their name, correctly. Let them know you see them.  Be a friend.
Clarify or restate what your spouse tells you when he is sharing his pain. Don’t interrupt.  It’s not time for sharing your feelings.
Remind your patient her medical record and your conversation is confidential. There are a few instances where you have to disclose what you’re told, be aware of those.
Establish trust, or you will never get truth.

I often ask my patients:

This is your life, are you who you want to be?

If not, what do you want to change, and how can I help?

What about you? What are your thoughts or reflections? Please share with me.

Hawaiian Tropic, Donny Osmond, and Tanning Beds

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Back in the day, I was a sun goddess.  Brown was cool and fish belly white was not.  My teenage summers were a blend of sleeping in, bumming around, swimming, and sunbathing. I’d start at Ten a.m. Dressed in my bikini – hard to fathom but at fifteen I was 5 ft 9 and 125 pounds.

Me and JeanI’m still 5ft 9.  Ok, back to the story.

Dressed in my bikini, I’d grease myself with Hawaiian Tropic Dark Tanning Oil, Turn the Radio on LOUD as living out in the country the only potential complainers would be the cows. And I would lay in the sun and bake.  Turn every thirty minutes, peel back the bikini bottom for a peek to assure good color, and call it a day before 2 o’clock.

Ah, the life of a 70’s teen.

no computers

So now I wait.  When’s the Basal Cell coming?  Is that mole a Squamous cell? Crap! I think I have Actinic Keratosis.  I’m DOOMED, I’ve established the foundation for skin cancer and all I can do is watch and wait.

And use sunscreen.

I can’t do anything to change what I did when I was young and stupid, but now that I know better, I do better.  According to The American Cancer Society, 

Most skin cancers are probably caused by exposures that happened many years earlier. The pattern of exposure may also be important. For example, frequent sunburns in childhood may increase the risk for basal cell cancer many years or even decades later.

The new bad boy on the block is tanning beds.  The tanning salons are everywhere, and the young, middle aged and even seniors are going on a regular basis for the relaxation and the joy of that golden bronze color. Sorry to be a bearer of bad news, but a new study confirms the indoor tan is a golden ticket to skin cancer.

The investigators found that indoor tanning was associated with developing skin cancer at an early age.

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In May, the U.S. FDA announced that tanning beds and tanning booths MUST carry a visible warning stating that the devices should not be used by minors under age Eighteen.

So far so good: no skin cancer for me. Now,  I stay out of the sun, have at least two dozen bottles of excellent sunscreens scattered about for easy access for me and my family, and I think fish belly white is beautiful and Donny Osmond is still cute.

Chief Complaint: Top Reasons We Go to the Doctor

P1110588The Mayo Clinic reveals the top reasons for health care provider visits:

  • Skin disorders: acne/cysts/rash
  • Osteoarthritis, joint disorders, and back pain
  • Cardiovascular problems such as high cholesterol, stroke
  • Upper respiratory conditions: cough, sore throat, ear problems
  • Anxiety, Depression
  • High blood pressure
  • Headaches, migraine, and other neurological conditions
  • Diabetes

That’s what the research tell us. If I had kept tabs on the thousands of people I have seen over the years, my list would look more like this:

  • 6 month and annual check up: AKA you have to come in to get a prescription refilled.
  • Respiratory: cough, cold, ear ache, allergies (or can I have an antibiotic)
  • Back pain
  • Hypertension management: usually smoking and obesity related health issues
  • Routine health maintenance: vaccinations, women’s care, sports, and work physicals
  • Other: I would include depression and anxiety here.  Rarely did I see patients calling in with depression as a chief complaint.  It was something else that brought them in (joint pain, stomach problems, sleep issues), and through talking it was obvious clinical depression was the root cause.

And then there were the surprises that made for a challenging day: thoracic outlet syndrome, lacerations, shingles, really big hemorrhoids, genital warts, foreign body in ear or other body openings (always very interesting), mono, deep vein thrombosis, melanoma, scabies, lice.  Why did I always start to itch after seeing a kid with lice?

As much as you hate the automated phone tree, co-pays, wait time, and general inconvenience of going to the doctor, don’t neglect your health.  If you take good care of it will repay you in kind.

heart health

 

Top 10 Reasons to Keep Smoking Cigarettes + 1 Bonus

cigaretteI love to help my patients quit smoking.  Both smokers and non-smokers agree: smoking is a terrible habit and is horrible for your health.  Smokers tell me that all the time!

I know this stuff will kill me, and it’s nasty.  My kids are on my case to quit.  Why haven’t I quit yet? Well, I plan on it, yessiree.  BUT….

…right now’s not a good time.  One addiction at a time for me.  I’m under a lot of stress. I can’t afford to gain any more weight.  I have four cartons left, I have to use them up first.  My husband refuses to quit with me, as long as he smokes I can’t quit.

Those are actual statements patients have said to me.  I respond with empathy:

Yes, quitting smoking is hard work.  Certainly, you are under considerable stress. True, I want you to be successful in your opiate addiction recovery. Definitely, a partner who quits along with you helps tremendously.  Maybe next time we can revisit this?

Am I helping by being understanding, and reassuring?  Or am I just dancing around the truth.  The truth is

quote

The truth is: you like smoking and don’t want to quit.

Can’t you just tell me the truth instead of coming up with the lame excuses? How can I help someone if they don’t want to change? Maybe I should reconsider my approach and try something like:

Top 10 Reasons to Keep Smoking:

  1. You keep me in business
  2. You keep dentists in business
  3. You keep tobacco companies in business
  4. You keep the government in business
  5. You get moody when you try to quit smoking –  keep smoking and stay happy
  6. Your Uncle Frank smoked 3 packs a day for over 50 years.  He lived to be 99
  7. Your wrinkles and puckered lips make me look better
  8. A husky voice is sexy
  9. You like being sick. It feeds your need for attention
  10. You already tried once to quit and you failed, why put yourself through that again, sheesh

Bonus: You get more frequent, longer work breaks than your non-smoking coworkers.

I don’t mean to sound harsh. Nah, maybe I do. When you see pregnant women smoking, dads hanging a butt off their lip while holding their child, teens parading their smokes in public, and folks in their prime of life dying from lung cancer, you get tired of the excuses.

And for the record, the average person only gains 10 pounds with quitting.

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It is better to offer no excuse than a bad one. George Washington.

5 Common Health Beliefs Busted as Myths

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Have you ever believed some health claim over the years and thought it was true because everyone repeats it? Did you ever question – really, where did you read that?  Or, how do you know that’s true?

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It may be common knowledge, but it doesn’t mean it’s true.  Let the believer beware: next time your workout buddy tells you your exercise routine stinks because you didn’t break out a sweat, ask where he learned that from.

Debunked: 5 common health beliefs busted as myths

  • You must drink 64 oz of water a day to stay healthy or lose weight

Fact: you should gauge your fluid intake based on your thirst and the color of your urine. Clear non-yellow hues is what you are “aiming” for. Dark yellow, amber, cloudy indicates your fluid intake is inadequate.  And no, your fluid doesn’t just have to come from plain water –  liquid beverages and the water in foods all help hydrate. However, if you drink calories, you are setting yourself up for weight gain.

  • You’ll get sick if you go out in the rain or cold without a jacket.

Fact: You’ll feel colder but you won’t catch a cold.  We do lose heat through our heads, so  wearing a hat or drying your hair makes sense if you want to feel warmer.

  • Don’t swallow your gum: It will never digest.

Fact: It will digest just fine and will come out your other end in about two days.

  • You should take a daily multi-vitamin.

Fact: Studies have shown multi-vitamins don’t improve your health.  What does? Eating a colorful, balanced diet.  What you would spend on vitamins spend on real, non-processed food.

  • Never read in dim light or you will hurt your eyes.

Fact: Your eyes may get tired but you won’t damage your eyes or permanently affect your vision.

For tons more medical myth busting, visit UAMS or email them your question: medicalmyths@uams.edu

Mencken quote

Back Pain: Don’t Make These 5 Mistakes

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Two days ago my dog spied his adversary chippy the chipmunk and pleaded for me to let him out. Since his discovery of the fawn nesting in our neighbor’s bushes, I’ve grounded him from all independent runs in our wooded back yard.  I put his leash on him and opened the door thinking the two of us would carefully walk down the back steps, he would do his business, and we would say hi to Chippy as we happily went back inside.

What was wrong with my brain?  Was it sleep deprivation? Perhaps my preoccupation with the days responsibilities? Whatever caused my sudden lapse in judgement is irrelevant now. I opened the door, and my dog bolted while I was holding tight to his retractable leash.

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After one step down I knew I was in trouble so I let go. Thanks to the laws of motion, I flew over the remaining 3 steps and hit the ground with a thump.  I was sure I broke bones and would be forced to lay there helpless, at the mercy of our evil garter snakes and my dog’s sloppy wet kisses.  It was 7:15 am – my husband out of town and my three teen boys lay sound asleep two stories up, door shut, fan on, and a good chance noise canceling headphones were still attached to their ears.

sleeping

If I couldn’t move I was doomed.

Surprisingly the only injury I seemed to suffer was wounded pride and a knee abrasion.  That was then. It took a day for my body to reveal the extent of the damage. Now, I write to you from my couch where I lie supine,  ice on my lower back and pillows strategically placed for optimal comfort.  It was not just my pride and knee that were hurt, but I messed up my back as well.  Back pain  sucks, but it is as common as vanilla ice cream. 85% of us will experience it at some time.  The problem with back pain is if it isn’t handled properly when it happens, it can result in over treatment, unnecessary diagnostic testing/referrals/surgeries, and can begin a spiral down into crippling disability and even opiate addiction.

The Don’ts of Back Pain:

  • Don’t ignore it – Pain is a warning sign that something is wrong.  Most back pain is mechanical, meaning it is from injuries such as the one I described, or its the result of poor body mechanics with lifting.  It is always a good idea to see your provider to have your back pain evaluated and so you can receive proper instruction on how to mend. Your provider will also assess for red flags.
  • Don’t baby it – The worst thing for back pain is bed rest. Give yourself 48 hours of limited motion, applications of ice, and Over-the-Counter pain relief, and then start rehabilitating through careful positioning, movements, and strengthening exercises. Avoid heat as it may feel good at first but can delay healing.
  • Don’t overmedicate it: No you don’t need narcotics.  I have many people in the addiction clinic that started on Oxycodone for their back pain.  Back pain can be adequately managed with Ibuprofen or other NSAIDs, and tylenol.  Use creative pain relief interventions such as trigger point massage, cold packs, gentle whirlpools, and distraction. According to U.S. Pharmacist.com:

The use of opioids for managing low back pain remains controversial. Opioids are the agents of choice for managing severe acute pain and chronic pain associated with cancer.

 

  • Don’t underestimate the importance of prevention: Prevention is the key to all back pain.  Practice proper lifting techniques.   Strengthen your core muscles.  Recognize potential fall hazards and avoid them.

  • Don’t remain ignorant: learn the latest treatment and diagnostic guidelines for back pain management.  You are doing yourself potential harm if you don’t know the difference between good care vs quack care.  Millions of dollars are spent on unneeded surgeries and overzealous practitioners who take advantage of your mechanical back pain and pad their pockets with your money.

An ounce of prevention is worth way more than a pound of cure when it comes to your back.  So stand up straight, be smart (don’t use retractable leashes), and be safe.  If you treat your back right, you’ll be waltzing on your 95th birthday.

Here’s to healthy backs! P1020954

Prediction: The ADHD Fad Is About to Fade

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Is ADHD really a fad diagnosis? Have you been told by your child’s teacher that your child, who is likely to be a elementary aged boy, is distracted, disorganized, forgetful? If you took away the requirement to be between the ages of 6-16, those traits could describe any of us.

My Prediction: The ADHD Fad Is About to Fade | Psychiatric Times

In the above article, Dr. Frances shares his research and makes a credible observation:

The tripling of ADHD rates in the last 20 years and skyrocketing use of stimulants are sure signs of a fad.

Dr. Frances also references to an eye opening piece written by Alan Schwartz of the NY Times. Mr. Schwartz exposes some rock solid evidence to support the inappropriate diagnosis of ADHD and the misuse of stimulants to boys to appease teachers who don’t have the time to deal with a kid who learns differently. How freakin’ sad is that?

Parents: Get enlightened.  This is your boy.  Fight for him.  Don’t cave in to the pressure to put your spirited, beautiful boy on meds unless he absolutely has the disorder and is suffering because of it.

THE FACTS
THE FACTS

Providers: Shame on you for giving out stimulants like they are some magic beans that will make all the kid’s problems go away.  How about looking at the evidence and do a let’s try these things first approach before you give the exhausted parent a quick script for Adderral.

Teachers: You are the reason I homeschool my three boys. No doubt you would have called me into a big old meeting and told me my son was not keeping up with the rest of his peers and had all the behaviors that pointed to classic ADHD.  Your expert psychologist would back you up with mumbo jumbo literature and intimidate me into making an appointment with my pediatrician and getting my son on medicine as soon as possible because after all, YOU are the expert. Not. You are so fortunate not to have had my sons in your classroom.

I am relentless when I need to be, which makes me good at what I do.

Adult dragons are,astute,powerful,and sure of their strength. Ciruelo Cabral
Adult dragons are astute, powerful, and sure of their strength.
Ciruelo Cabral

Are the drugs used to treat ADHD truly  “nuclear bombs, warranted only under extreme circumstances?” 

It’s tough being a parent. It’s tough being a kid in a public school system.  It’s tough to be a teacher in an overcrowded ‘teach to the test’ public school system. And, it is hard being the provider who has only fifteen minutes to listen, exam, and evaluate.

That’s why we all need to take a step back and look at the evidence.  Let’s not be quick to assume the problem is ADHD.  It could be. But it’s probably not.

If it’s my kid, I will try anything and everything before I resort to medications. If he is however, one of the 5% of kids who has true ADHD, then I will gladly take the prescription and once again thank God for modern medicine.

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Why Does My Patient with Lung Cancer Keep Smoking?

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What does it mean to have blinding ignorance? Isn’t ignorance just ignorance? Why does Leo add on blinding?  Was it because something so clear to him was completely misunderstood or purposely ignored by his peers and people of his day?  Sigmund Freud once said that Leo was like a man who awoke too early in the darkness, while the others were all still asleep.

Ignorance

If you think about something that is blinding, what do you picture?  My first thought is coming out of a dark movie theater on a beautiful sunny day.  I’m squinting like a mole ’til my pupils adjust and I can focus.

Are you like da Vinci, awake while others are sleep walking? Or are you one whose eyes are shut? How do we know which camp we fall into? To be misled is one thing, but to be misled by our own blinding ignorance is indeed a wretched condition.

I recently saw a patient who was diagnosed nine months ago with lung cancer.  Stage 3 with mets to the brain. A smoker?  You bet, for over 40 years.  She’s gone through chemo, and now faces radiation to the brain.  Has she stopped smoking? Nope.  I asked her why she hasn’t quit.  Her reply:

I’ve cut way down.  I’m going through a lot, and smoking helps me deal with it.  I know I need to quit.  I’m working on it.

I encouraged her, and remarked that I was proud of her progress. Yet I couldn’t quite wrap my mind around continuing with a behavior that is killing you.  A strange thought coming from a person like me who works in addiction medicine.

I would expect a woman who has a potential of 30 years left might consider lung cancer a wake up call and quit smoking. Does she have blinding ignorance?

How do I help her? Can she be helped?

How do we wretched mortals get our eyes open?

You never give up. Try another approach, don’t preach, lecture, yell or use over the top scare tactics. Habits are hard to break.  Addiction is a tough disease, ignorance is too. Fall down twenty times, get up sixty.  No matter what, never write someone off as too far gone.  Where there is breath and movement,  there is life.  Where there is life, there is hope. Blinding conditions are temporary.  Sooner or later, the eyes adjust and can see.

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What are your thoughts?

Could Your Bad Headache Be Meningitis?

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Headaches are common, often caused by tension in the muscles, lack of sleep, allergies,   prolonged hunger, or other non life threatening triggers.  When is a headache more than just a nuisance but a sign of something dangerously wrong?

Any headache that is different than what you are used to, occurs in the very young or old, is accompanied by other symptoms such as light sensitivity, a stiff, painful neck, nausea/vomiting, or comes on like a thunder clap, needs immediate attention.

Get thyself to thy doctor or emergency room stat!

when in doubt

Let’s consider meningitis, an inflammation of the brain that can cause sudden onset of headache, fever, stiff neck, and nausea/vomiting. All kids/teens are immunized against the most serious bacterial meningitis with Menactra, but there are some people who can become infected with a different pathogen and become gravely ill.

Any new headache is potentially worrisome. Add on other symptoms and there is no question their is a need for prompt, further investigation: emergency room visit.

Hey, this doc is worth watching! He will give you a one minute run down on meningitis.

Stay informed, stay healthy.