People think I'm crazzzy...

My pediatric clinical rotation is in full effect, and I love that it coincides with the start of the school year.  Every day is jam packed with parents propping their kiddies on the table and coercing them to say one of two statements 1. "I need a refill on my ADHD meds" or 2. "My ADHD meds aren't working".  I then reply with the same question for every patient "why do you think you need ADHD medication?"

My question usually causes an immediate look of dissatisfaction from parents. I mean, children need to know why their parents are giving them 20 mg of Vyvanse every morning and 25 mg of Strattera every night.  The children usually respond to my question with the same response "My teacher (or Mom) says I move around too much".

Um, isn't that what children are supposed to do?

Case Study:
AJ an 8 yo boy presents with his mother and younger brother to get his ADHD medication changed. Both AJ and his mom state that his teachers are complaining about him not completing tasks, losing focus and his inability to remain still in his seat. AJ doesn't have an IEP (individualized education plan) and gets no classroom accomodations, such as small group sessions, additional testing time or tutoring. AJ's mother confesses that she doesn't have a problem with him at home. AJ participates in band on Saturday mornings. His band instructor says AJ is a great student and exhibits no behavioral problems.  AJ's is currently taking Vyvanse 20mg every morning. What do you do for AJ and his mom?


Response:
First of all, not every child that moves around in his seat and doesn't complete tasks has ADHD. If that's the case, my entire 1st grade class had it.  Sometimes, I know a lot of teachers won't admit this but sometimes children are bored and probably aren't being challenged to their full potential.

Nonetheless, appropriately diagnosed children with ADHD don't always need medications (some absolutely do) but rather an individualized plan that caters to their academic needs. My preceptor gave me and AJ's mom some really good information regarding ADHD.  Children with ADHD are very creative. They love the arts, they love being imaginative and portraying fictional characters and events. Health care providers must partner with teachers and parents to tap into their creativity and focus less on medicinal remedies. Relying on drugs to correct ADHD directly correlates with drug-seeking behaviors seen later in adulthood.

We are going against everything we spent 20 years teaching children on afterschool programs:
JUST SAY NO TO DRUGS!!

Baby Bucks

In my quest to further understand our health care system and how it benefits my patients, I ordered a documentary on Netflix called "The Business of Being Born". The premise of the film is to show how delivering babies has shifted from a natural process to being a well orchestrated medical situation.  The film chronicles several pregnant women including Rickey Lake, the ex-talk show host, through their various birth experiences.

The real take-home message from this film is that our society has turned the process of being pregnant and giving birth into a medical condition and thus downplaying the significance of nurse midwives.  Take a look at this video...

Movie Trailer for The Business of Being Born

A midwife is an advanced practice nurse with extensive formal training in caring for pregnant women and delivering healthy babies. They can work in hospitals, birthing centers, and in your home. These professionals function in a similar capacity as nurse practitioners, in that they can manage yeast and urinary tract infections and STIs.  If you need a well-woman exam, they've got you covered.  While there are thousands of nurse midwives in the United States less than 3% of American woman utilize their services.

Unfortunately for nurse midwives, most women prefer to have their babies in a hospital under a doctor's supervision. This isn't always necessary seeing as though at least 80% of pregnant woman are low-risk and would greatly benefit from the expertise of a nurse midwife.

Check out these fun facts:

• Midwives attend over 70% of births in Europe

• France has the lowest infant mortality rate

• US is ranked #37 in infant mortality (two spots above Cuba)

• US is ranked #39 in maternal mortality (this number has increased from 11 to 16 per 100,000 since 1990)

The moral of today's story is ASK QUESTIONS and do your research. Should every woman go out and get a nurse midwife? No, because it's not for every woman and her situation. BUT every woman should be informed.

We spends hours researching the safest cars, car seats, strollers, etc. Shouldn't we research the safest ways to have our babies.

Food for thought.....

Gone but not forgotten...

So, the semester has finally ended. I prayed for this moment the day my women's health course started. Unfortunately I miss my beloved speculum already. My awesome preceptors and fabulous mentors Dr. J. and Dr. C.L. totally changed my grimey view of certain male and female body parts. I thoroughly enjoyed teaching woman self-breast exams; despite the fact that the U.S. Preventative Services Task Force says that its a waste of time. I met many woman who found the thought of feeling their own breasts unsettling. There were even more woman who thought looking at their own vaginas was repulsive, and yet they allow strangers to look at them and touch them and they often don't remember these peoples' names. Ummmm...no comment.

I also loved teaching young, first-time moms about maintaining their bodies during pregnancy. You would be amazed at how many pregnant woman get STIs during pregnancy. For example, a 23 yo patient presented 6 weeks pregnant, she tested positive for chlamydia. The nurse midwife strongly suggested that her partner get treatment and that she refrain from sex until after delivery. She presented one month later complaining of a weird discharge. She had trichomonas. I mean really!! So this time I not-so-subtly demanded that she shut down shop until she delivers the baby. Nothing is that good to risk endangering your unborn child.

That being said, I have registered to become a certified prenatal educator. I want to create an environment where young moms can ask questions and receive honest answers, and yes sometimes "Mama Nikki" will come out and tell them the real deal. 

I had a challenging but wonderful summer semester. I have three weeks to prepare for pediatrics in the fall...the saga continues. LOL

Tryin' to be grown...

While completing my women's health rotation, I have had several opportunities to educate our poor misguided teen girls, and at the same time commend them on making some responsible adult decisions.  I have encountered several young adolescent girls who present for birth control and/or STI testing. Now I don't know about you, but when I was thirteen I was making friendship bracelets, reading The Boxcar Kids and trying to convince my mama to let me watch Dirty Dancing. (or maybe I was a little slow)

Fortunately and unfortunately, the state of Louisiana deems 13 an appropriate age to request STI testing without parental consent.  What I find difficult to understand is while they (meaning teenage girls) are so well versed in all of the ways to have sex, they have no idea what STIs are or what happens during a pelvic exam.

My most recent experience involved a 15 year-old female who wanted STI testing and a pelvic exam. This was her first pelvic exam. We discussed the various infections and took a look at the speculum and how it would be used. Her eyes almost popped out of her head when she saw the speculum--mind you it was the smallest one.  She jumped off of the table stating she couldn't get the exam because she was scared. I, the person my high school classmates called grandma, had to give sista' girl a little tough love. I told her, in so many words using the most composed voice I could, that if she was going to do grown folks' things she had to go all the way.  I also told her that she is the only person responsible for her sexual health. And maybe I mentioned that the speculum was smaller than the average penis. (Minor detail). She barely knew when the exam was complete.

Teens need to be educated about healthy sex practices because guess what just sayin' no doesn't work as well as it used to. I don't know about you but I dont want a whole bunch of sexually-irresponsible teens becoming our nation's next leaders, but wait that's already happened. Advanced practice nurses need to stay abreast of new STI guidelines because you never know when you may encounter one, even in specialty practices. Lesions are popping in some unconventional places, and that's partly due to the growing variety of sexual acts.

Nonetheless at the end of the day, they are still just kids. So do as I do, take a deep breath (and in some cases you may want to hold your breath) keep a gentle face and treat them like the adults they are so desparately trying to be.

Pelvic Exam Queen

Once upon a time about 15 years ago I got my first pelvic exam. It was a horrifying day, not because I had a horrible doctor (Dr. Blair is awesome) but because there was a huge metal-looking duck bill expanding inside of my vagina.  The image has stayed with me over the years. Now, I, Nurse Nikki, the FNP student am performing about 15 pelvic exams a day with those same metal duck bills.  During my first attempt I'm pretty sure I hesitated about 3 times before I actually inserted the speculum.  My ultimate goal is to minimize discomfort and any traumatic experiences to what is already, for first-timers at least, a mentally exhausting but necessary event.

Everyday I strive to improve my technique and decrease discomfort. I think the key to a successful pelvic exam is all in the patient's position. (My preceptor at Planned Parenthood is an awesome teacher) Instead of positioning the stirrups in an awkward outward position, I place them slightly parallel and ask the patient to then point her knees outward. Her legs resemble a frog's legs (for you visual folks). With her bottom on the very edge of the table and knees outward, this creates optimal viewing. I refrain from a whole lot of touching just because it's not totally necessary. A simple and light touch to the inner thigh alerts the patient I am about to begin. A comforting reminder to relax also helps. Sometimes a little pressure to the introitus is necessary to initiate relaxation.

Needless to say, I am by no means striving to become a women's health nurse practitioner. I commend them for their ability to simply focus on the female genitals for entire work days. I love primary care and its always in the back of mind.  I always manage to add a few questions about cholesterol, glucose and weight management into each visit.

So I have about 10 more days left of performing about 10+ pelvic exams a day. I'm pretty sure that makes me the Queen of Pelvic of Exams (in the student category of course).

Blog Launch Weekend: AANP Conference 2011 Las Vegas!!

My first AANP national conference! Once my plane touched down in Las Vegas, I was inspired to channel my energy into an anedoctal and hopefully inspiring blog.  Follow along...

I got off the plane with a nervous giddiness. I wanted to see it. 'See what?", my husband wondered as I dragged him along. "Nevermind, give me the camera, no, better yet I'm faster with my camera phone". "What are we trying to see", he shouted. "I want to see the sign, the sign that says Las Vegas welcomes the The National AANP Conference". We hurried to baggage claim. There was a sign for a Rihanna concert, some hot-looking Chippendale dancers, a human Mufasa, but no AANP. No mention of us anywhere. Maybe Las Vegas put the sign outside. We proceeded to the shuttle line. A quick sweep of the area still revealed no sign.

I didn't let a little sign, spoil the occasion. I was in Las Vegas for bigger reasons.
Project: Save Lives
Operation: Educate My Patients
Mission: Empower Myself

This minor case of disappointment made me realize folks are still a little greeen about nurse practitioners. Its a little frustrating pursuing a career that I have to teach people about before they allow me to touch them.  I hope to use this blog to vent my frustrations, jubilations and realizations as a 3rd year NP student and later as a new NP. Other nurse practitioners: new, old and students can use it as a platform to voice their questions and comments as well.

Small Disclaimer: Don't expect APA format because it ain't happenin'!