OB, oh boy!

It pleases newFNP that she continues to experience new challenges in clinic.  Otherwise, the work gets a little too rote.  Thankfully, newFNP's prenatal practice has been supplying her with a couple of not taught in school-style scenarios.

In the past week, newFNP has had five patients on the verge of labor.  Generally what happens is that newFNP educated patients on when they should go to labor & delivery and, with the exception of her eighth-grader in labor, that is what happens.

Not so much this week.  One patient presented for her repeat c-section, ineligible for VBAC due to her first c-section being conducted vertically, checked herself into the hospital and then checked herself out, only to drive to another hospital where she had the cesarean.  Another patient presented to her c-section appointment because her fetus is stubbornly breech, only to be turned away and instructed to return in a week.  NewFNP scheduled this c-section according to the hospital's protocol for breech position, not according to her own whimsy.  Whatever.

Finally, not once, but twice in the past week, newFNP has had patients present to the clinic in labor.  Her most recent patient (G3P2) was three days post-dates and had a urine dip that screamed UTI and dysuria to boot.  To top it off, she was contracting every three minutes in the exam room.   She was laughing through the contractions and they were only lasting about 20 seconds.  NewFNP, however, was not laughing.  

Here was newFNP's conundrum.  It was simple really: treat the UTI with some Rocephin and then send her to labor  delivery or just send her to labor & delivery.  Truly, newFNP thinks that either way would have been fine.  But she prefers to TCB in the clinic, rather than shuffling her patients off with business left to take care of.

NewFNP called her Family Practice MD colleague who advised her to do a vaginal exam to assess for cervical dilation and effacement, give the Rocephin based on what was going on all up in that and go from there.  

Here's the problem: newFNP doesn't totally trust her cervical exam.  She just hasn't done enough of them on pregnant ladies in labor.  Sure, if she could put her head in there with a miner's light, she could easily tell if that action is dilated.  But on a 232-pound lady who is 10 months and three days pregnant, the exam is not so easy for newFNP.  Nonetheless, newFNP strode back to the room, sterile gloves in hand, and proceeded to examine the hell out of that cervix.

And folks, that was a good cervix to assess.  NewFNP felt 5-6 centimeters of dilation and nothing but head.  NewFNP's patient, shocked, just kept laughing through the contractions.  NewFNP called her MA to deliver the Rocephin, called the prenatal coordinator to deliver the taxi voucher as her patient had driven herself to her clinic appointment, had her call her truck driving husband and ask him to turn that action around, and sent her on her way.

She gave birth to a healthy 9-pound girl a few hours later.

The fifth patient just went to the L&D floor as directed.  

So, all in all, 20% of these ladies had labors that went down as newFNP had anticipated.  Doesn't matter.  All that matters to newFNP are healthy moms and babies.  

Girl, you'll be a woman (far too) soon

NewFNP is just going to put her bias right out there: if not a single teenager ever got pregnant again, newFNP would be just fine with that.  Sure, having a baby when one is in the 10th grade is not the end of the world.  It doesn't absolutely mean that one will never, say, graduate from high school or attend college.

But it sure as shit makes it more likely.

NewFNP concedes that it is utterly possible that the 16-year old sitting in her exam room, pregnant with twins, was not necessarily college-bound to begin with.  Most of her patients do not go on to college, but newFNP makes it a practice to plant the seed in her pediatric & adolescent patients that they have options and that college is a very good one indeed.  NewFNP recognized her patient's mom as one of the women who regularly sells champurrado outside the clinic from an orange Igloo container.  Maybe college has never been thought of as a possibility for her children, never been discussed in the family.  Maybe grandchildren will bring more joy than will the pride associated with watching your child succeed academically - newFNP just doesn't know.

NewFNP moved between the medical and social histories with this patient.  Tenth grade.  Lives at home.  Planning to continue the pregnancy.  Medical history insignificant until now.

When she inquired as to the father of the twin fetuses, her patient replied that he was involved.  

Great - that is a good start.

"Is he in school?," newFNP inquired.

"No," her patient replied, eyes averted.

"What is he doing?"

"He's working."

"How old is he?" newFNP asked.

"Twenty-three," came the sheepish reply.

Somewhat shocked, newFNP turned to her patient's mom and asked her what she thought about this.  She replied that she thought her child's Casanova was a good guy.  

NewFNP almost fell off her rolly stool.  It is a situation such as this in which newFNP imagines herself going vigilante in her hypothetical parenting world.  This is a man and a girl.  This is statutory rape.  This is one of the many reasons that newFNP is a huge fan of the birth control pill, the IUD, even the shot (of which, truth be told, newFNP is no real fan).

Her patient's mom told newFNP that she had instructed her daughter to be careful.  Be careful?? Has this mom never met a twenty-three year old man before?  Because newFNP has, and she knows that they are horny motherfuckers.

NewFNP referred the girl to high-risk OB and to pregnancy case management.  She reminded her that quitting school was not an option, that she would, in short order, have two children to support and that those children would look to her for guidance.  

It wasn't one of those encounters that newFNP walked away from feeling hopeful about the future or inspired by her work.  

She just felt sad.  And disappointed.  And angry.  At herself for not being a better counselor, at the mom for not helping her daughter get contraception and for condoning the relationship and at the guy for dating a high school student.  

Out of the rut, follow the gut (instinct, that is)

NewFNP has been caught in the hum-drum of sameness at clinic.  Paps, prenatals, diabetics, URIs.  These are the norm of clinical practice, but the routine gets a little drab.  Don't get newFNP wrong - she doesn't want to work in a emergency room, but she does like a little change-up here and there.

She got it.

NewFNP was doing an abdominal exam during a well-adolescent visit.  The kid was fourteen, had no medical history to speak of and had no complaints.  Nonetheless, the instance newFNP palpated his belly, her internal alarm sounded.

This young man was not especially skinny - just average with a smidge of baby fat.  Had he been thin as a rail, newFNP would not have been so startled when she felt his abdominal aorta pulsating very prominently and pulsating a full two finger breadths to the right of the umbilicus.  She attempted to measure the aorta and estimated about a three-plus inch width.  

NewFNP spent a while running this through her mind.  She didn't feel a mass and she could not determine the direction of the pulsation.  The only thing of which she was certain was that this exam did not feel right.  

She got Dr. Dual-Ivy-League-Degrees to consult -- she agreed that it was an unusual exam.  

Maybe this is normal for him, but son-of-a-bitch if it's an aneurysm.  What are the odds at fourteen years old?  Un-frigging-likely.  Nonetheless, newFNP trusted her gut and sent him and his gut for an ultrasound.  She is anxiously awaiting the results.

Dress code violation

The inappropriate t-shirt trend has followed newFNP to the research clinic.  The reach of the inappropriate t-shirt is, apparently, far and wide.

When newFNP saw her patient filling out forms in the waiting room, she did note that his shirt said "F.B.I." across the chest.  NewFNP naively thought that this gentleman seeking to participate in a research study about methamphetamine addiction was perhaps showcasing a touch of irony.

Not so much.  Upon closer inspection, newFNP notes that underneath the "F.B.I.", the shirt read "Female Body Inspector."  Classy.  The only female body part newFNP will let this fellow inspect is her stank eye.

But the self-appointed Female Body Inspector had nothing on the wildly inappropriate t-shirt that another research participant was wearing.  This shirt was a walking advertisement for the metal band Cloven Hoof.  This shirt featured a graphic of a mullet-man orally pleasuring a woman.  Charming.  NewFNP gets it - figuratively - and she is none too pleased.  

When newFNP gets dressed in the morning, she does the usual mirror checks: no VPL, no muffin top, no boob overflow, no totally fucking offensive t-shirt.  Check, check, check and most definitely check.

I mean really.  Cloven Hoof?  Cunnilingus?  What makes someone purchase such a shirt?  And then what possesses someone to wear that shirt to a medical clinic?  

Yuck.

Action!

What's up, nurses?  We're fucking famous, that's what.  Or maybe nursing leaders are in cahoots with the entertainment industry to make nursing appear to be a more attractive profession in the face of a horrible nursing shortage.

Not one, but two new TV shows with nurses as lead characters!!  Showtime's Nurse Jackie and TNT's HawthoRNe.  

NewFNP's hope is that the TV shows will do nursing justice and that the characters will be interesting and complex and funny and smart.  It's newFNP's fear that a recurring dynamic is going to be the physician-nurse tension as is showcased in the HawthoRNe commercial.  That dynamic is tired.

NewFNP's money is on 'Nurse Jackie'.  It has Edie Falco, it's on cable and on the same network that brought us 'Weeds' and 'Huff', it has a nursing student character and it appears to have been thoughtful in its character development.  

And if the show's writers need any technical assistance with the science and art of nursing or with story line development, newFNP shall avail herself to them!

You down with PCP (yeah, you know me)

It cannot be stressed enough - the 30th patient of the day must not - repeat not - be difficult. That patient could be clinically complicated but personally reasonable or that patient could have a "gimme" diagnosis. NewFNP's favorite is UTI, but she could go for an otitis media or a fungal derm as well.

NewFNP isn't sure how to triage for this when scheduling appointments, but if she could develop an algorithm for optimal patient scheduling that ruled out end of day challenges, she could retire and buy an S4 and some Tory Burch tunics.

As newFNP perused patient #30's chart before entering the room at 4:40 to begin said patient's complete physical, she noted that another provider had charted "PCP abuse."

PCP? NewFNP glanced at her watch. She had not, in fact, used her flux capacitor and time travelled back to 1983. It was firmly 2009. She imagined that the demand for PCP would be minimal and that this patient's dealer might have a 2-for-1 special or a sign that screamed, "PCP - no waiting!!" whereas the lines for meth and crack would loop around the block. Of course, truly, newFNP has no frigging idea about PCP procurement. And even more significantly, she has no idea about PCP addiction treatment.

So newFNP goes about the social and medical histories which, as one might imagine, were both colorful and sad, and got around to asking about the PCP. She had been smoking PCP on and off for over 20 years.

"When was the last time you used PCP?" newFNP asked?

"Well, it stays in your system for a long time," #30 replied.

Hmmmm. It's an answer, yes, but it's an answer to an entirely different question.

"Oh, OK," newFNP responded. "So about how long ago was the last time you used PCP?"

"I want to stop," #30 replied. "It's hard to be a mom."

NewFNP imagines that it is hard to be a mom and that anyone would want to stop PCP use. Still, that nagging little question was stuck in newFNP's craw. NewFNP acknowledged her patient's desire to stop and assured her that she would receive a referral to behavioral health/addiction medicine treatment. But she had to ask.

"I'm sorry but I'm still unclear as to the last time you used PCP," newFNP gently prodded.

"I told you already!" #30 exclaimed.

"I don't think you did," newFNP stated. "You told me that you wanted to stop and that PCP stays in your system for quite some time. But I don't know how long ago you used."

"A month ago," she stated, as easy as 1-2-3.

The thing about PCP is that its lore is full of horror stories - people thinking they can fly while intoxicated, people exhibiting superhuman strength, people having delusions and behaving violently. And it's an hallucinogen, a class of drugs for which there is a paucity of documented treatment modalities.

So, after a month of not using in the face of all the same life stressors as are always there, how does someone maintain abstinence?

NewFNP gave her a counseling referral and some encouragement, but that's not really enough. Unfortunately, it's all many primary care providers have to give. Mental health and addiction treatments are expensive and not adequately covered under insurance plans and certainly not under this woman's public insurance plan.

Maybe newFNP should refer people to Intervention - let Jeff or Candy give it a whirl.

Rack 'em up

NewFNP is back from her conference and - you know - nothing says 'welcome home' like a diagnostic mammogram!  As she prepared for her appointment and dutifully neglected to deoderize and moisturize, she reminded herself not to worry until there was something to worry about.  She arrived at her fancy-pants medical center, registered, donned the wristband and was called back to get changed.

She changed into her seersucker gown in the mammography center dressing room and glanced at herself in the full-length on her way out.  The mammo-gown was actually flattering.  They must have had DVF design the fucking thing.

Having never had a screening mammogram, newFNP is not quite certain as to the extent of its torture but she will say this: the diagnostic mammo is no way to get initiated into the world of breast imaging.  Eight views - none pleasant.  

NewFNP didn't realize that, in addition to the breast tissue, the mammography technician would need to manipulate her xiphoid process into the images.  

When her sweet as could be technician finally got newFNP's breast flattened so as to resemble a fucking crepe, she - in all seriousness - told newFNP not to move.

"Honey, I wouldn't dream of it," newFNP responded.  After all, newFNP rather likes having two generally symmetrical breasts and felt quite certain that any attempt at escape would be a) futile and b) mutilating.  

Although newFNP made light of her situation with her technician, she couldn't help but to feel a twinge of worry.  Her face must have betrayed her worry and a kind lady in the waiting room commented on what a horrible waiting room we were in. 

NewFNP agreed.  The woman told her that she had her first mammography at 37 and that her mother had died at a young age from breast cancer.  She went on to say that she had had "a thing" removed a few years ago.  It was benign.

"I have a thing," newFNP told her.  Although newFNP knows it is benign, it felt oddly good to unburden herself to this lovely and kind stranger.

"You do not worry until there is something to worry about," the woman told newFNP, echoing her very own thought.  "That is not denial," she said as we stood together to schedule our next appointments - hers in one year, newFNP's in two days for ultrasound.

(NewFNP made the follow-up appointment, but could not help but to think that she is caught in the middle of a CYA-medicine spiral.  Is the fine needle biopsy next?)

NewFNP and this woman finished their boob and metal sandwiches at the same time and walked down to the valet together.  As the valet drove her car around, newFNP commented that we have the exact same car.

"It was meant to be," she said and gave newFNP a caring smile that made her believe it was true.