Saved yet again

Last week, newFNP had had it. She never wanted to return to clinic again. She had one especially bad encounter with a patient that left both parties feeling upset and involved newFNP telling the patient, "Pregnancy is not a disability - you do not need to quit work yet" in a not-so-nice tone and the patient telling newFNP, "You don't understand -- your job is easy." To which, of course, newFNP had an internal fit of apoplexy. It is a damn good thing that newFNP does not know how to say, "You have got to be fucking kidding me" in Spanish.

That, coupled with a few other institutional issues, prompted newFNP to send her resume out early yesterday morning.

And then, newFNP'll be damned, but wouldn't you know it if a patient reached out and touched newFNP in a way that made her love her job all over again. No - in a way that made her want to stay in her job.

This patient is in her 60's, she is a university retiree from newFNP's public health alma mater, she has Crohn's disease, is a breast cancer survivor, fell and had a major knee surgery two months after her chemo ended and was determined to be unable to care for herself post-operatively in her home as she lived alone. Thus, adult protective services placed her in a hella ghetto senior's community a stone's throw from newFNP's clinic which, in case anyone has been sleeping for the past four years, is in one hell of a shithole area. Prior to this determination, she was living in a peaceful suburb in the foothills of newFNP's city. She hasn't had a mammogram in two years and she is only three years post-mastectomy. She hasn't had GI follow-up in over a year. She feels as though she cannot turn to her children for help.

As she recounted her story to newFNP, newFNP just took a moment to acknowledge the hell this woman had been through and asked her if she wanted to talk to a counselor. She made an expression that spoke of her pain, of her sorrow and of her relief in being offered .

She shook her head slowly, ruminatively. "I could use it," she replied, nodding. "It has been a really hard couple of years."

NewFNP put down her pen after having filled the past medical history form and then some on this woman's encounter form, leaned forward toward her patient and said, "I am going to help you." And she meant it -- she meant it more than she usually does. And she felt the importance of helping this woman more than she has in quite some time.

And she did help her. She got her a mammogram even though mammograms are booked through 2010. She got her a counseling appointment. She overstepped her bounds and gave her a friend's email address in the hopes that this friend had some insider knowledge regarding other communities available. She listened. She cared.

But equally as importantly for newFNP is that this woman helped her. She saved newFNP from utter desperation and frustration with her job.

What a wonderful gift newFNP received today. She is so thankful.

One week follow up

Followers of newFNP may recall that last week she sent a gentleman to the emergency room with a temp of 102.3 and purulent nasal discharge. The day she sent him, he has come to clinic on his bike. When El Conejo was a no-show, newFNP told him that she would get him a cab and that he could lock up his bike at the clinic.

At that time, newFNP had no way of knowing how fortuitous it would be to store his bike for him.

He came today to pick it up, telling newFNP's MA that he was there to pick up his "Mercedes." As newFNP's MA took him to unlock his bike, he told her that the emergency room physicians had drained a lot of pus from his face and told him that if he had waited one more week, he would have lost his eye. He was hospitalized and given IV antibiotics for a week.

He was also diagnosed with leukemia.

Unfortunately, it makes sense. Why would an otherwise healthy 39-year old guy have 6 months of purulent nasal discharge and weight loss? At the time, newFNP was thinking immunocompromise due to HIV. (He had never tested positive, but newFNP was just trying to make sense of the bigger picture.) She had not thought of leukemia when she decided to send him to the ER.

Learning of his diagnosis A) reminded newFNP how crucial it is to consider patients in context and B) made newFNP feel so relieved that she sent him for further evaluation and treatment. Sadly, she knows that in other clinics, he would have received antibiotics and been sent on his way. He's poor, uneducated and uninsured. Maybe he would have gone to the emergency room when his eye was beyond saving. Maybe the infection would have overwhelmed his compromised immune system.

The silver lining is that his purulent nasal drainage is resolved and he has oncology follow-up scheduled. That is one hell of a silver lining.

NHSC ya later!

It's official, bitches!

NewFNP received a certificate and a letter today noting that she has completed her service commitment. Hells yes she did -- a year ago! But newFNP is inclined to disregard the delay and feel thankful that her brand name nursing school was paid for and that her three years in community health indentured servitude offered her an education in and of itself.

In retrospect, worth it. Worth every tear and every ounce of frustration. But she's not running back to sign up for more.

Sunken treasure

There are a few things which, if found in her bathtub, newFNP would wrap in a cloth napkin and tuck away in her lingerie drawer for safe keeping. These include a Harry Winston 3-carat flawless diamond, a bar of gold bouillon and a love letter from George Clooney begging for a second date.

What she would not keep is a year old Mirena IUD that had spontaneously expelled itself from her daughter's uterus.

Granted, newFNP does not have a daughter, let alone a daughter old enough to have an IUD, but she's quite certain that if presented with that scenario, she's not keeping the IUD as some progestin secreting family heirloom.

But this is exactly what happened. NewFNP's patient presented to have a new IUD placed but had no evidence that the IUD string hadn't ascended rather than the whole damn thing falling out. Did she see the IUD or feel the IUD expelling? She did not. Her only proof of expelled IUD was the return of a normal menstrual period after a menses-free year. Sadly, that is not grade A evidence. NewFNP unsuccessfully hunted for strings and then filled out the referral for an ultrasound to confirm expulsion. A uterus is, after all, designed for only one IUD at a time.

Her patient went home and got on the horn to make the ultrasound appointment. Her mom, also a patient of newFNP's, overheard the conversation and, with a sly smile on her face, presented her daughter with a daintily folded cloth napkin. Inside was her Mirena.

Why? Why wait? Why keep the IUD and not let one's daughter know that she is no longer effectively contracepting? Why keep it?

It's all so confounding for newFNP.

And hey -- let's just put that napkin in the trash, shall we? If ever there were a situation that called for cloth napkin wasting, this is it.

You're either in... or you're out!

NewFNP does not love to start her day with a veterinary emergency. Three hundred dollars later, her dog is on the mend and stoned on muscle relaxants. NewFNP needs a more affordable vet.

She furthermore does not enjoy it when she leaves her convalescing dog alone, pushed the power button in her car and finds the tire pressure warning light illuminated when there is no discernible flattening of tires. Those lights just stress newFNP out! To make matters worse, the frigging Prius has a warning light for everything. Too dirty? Warning light. Country music? Warning light. Bad hair day? Warning light.

And then twenty-nine patients later, she can think of some other things she isn't super fond of.

For instance, a 39-year old male with copious purulent and possibly necrotic nasal discharge. It wasn't that newFNP wasn't fond of him. It was that she experienced more of a visceral olfactory aversion. This poor gentleman smelled like a walking abscess. It was challenging to be in the same room with him. This has been occurring for 6 months. NewFNP posits that he has neither a roommate nor a partner. She hopes that he just has a horrible sinus infection or an abscess and not some type of tumor sloughing off. Truly, the smell. She decided to send him to the emergency room which is when he broke her heart a little bit.

She asked him to call someone to take him as she felt she couldn't justify the ambulance ride. He called El Conejo who agreed to pick her patient up at clinic and take him to the ER. NewFNP asked for his friend's name so she could leave it at the front desk and have the reception staff direct him to the back office. Her patient didn't know his friend's real name -- just El Conejo, the rabbit. He never showed. Is it a shock? This man must be so isolated and lonely that he called someone whose real name he does not know to take him to the emergency room. Ouch. NewFNP fed the patient leftover potluck lunch while he was waiting, gave up on the rabbit and eventually put him in a taxi, a sure-fire guarantee that he'll arrive at the emergency room.

Then she examined a patient who told her that she had an allergy -- to hot water. Just hot water. Does she shower in tepid? What if it's cold out?

But what newFNP is fond of is her new cute and affordable (!!) shoe find: Tsubo. In the quest for fashionable and comfy, newFNP has struck pay dirt.

And now she can relax with her dog, eat lucques olives, drink some wine and watch Project Runway. And of these things, she is quite fond.

No. Just no.

Fucking pancreatic cancer.  It is a goddamn awful diagnosis and an exceedingly difficult one to make until it's too late.

Perhaps that is why newFNP's patient received her diagnosis when the tumor was already unresectable and had metastasized to her liver, intestine and lymph nodes.  

NewFNP took one look at her today and knew that something wasn't right.  She had lost way too much weight for that amount of time, and not in a healthy-appearing way.  NewFNP had seen her six weeks ago and noted scleral jaundice.  At that time, she drew STAT labs.  Her acute hepatitis panel was normal, her bilirubin, alk phos, AST and ALT were sky high.  NewFNP's colleague sent her to the emergency room where, during the course of her three-week inpatient stay, she received her terminal diagnosis.

She was born the year after newFNP -- she in in her 30's.  She has four kids under the age of eighteen.  

She has three to six months to live.  If that.  Her oncology appointment is in four weeks -- too long a wait when every week is one of the last she has to spend with her family.

NewFNP is absolutely fucking heartsick about this.  This is a woman who was abused by her former intimate partner, who suffers with symptomatic myasthenia gravis and who has diabetes.  NewFNP cannot believe that after all this woman has gone through, she is going to die.

NewFNP couldn't bring herself to say this to her.  She is, after all, not an oncology NP and she didn't have a quantified prognosis in the very well-organized three-ring binder of information from the hospital.  She told her patient that this is a very serious diagnosis, that the physicians in the hospital had determined that the tumor was inoperable, that there is no cure.  She referred her to the medical-legal partnership to seek out health insurance coverage and, horribly, to draft a will when she is ready.  (As though someone could possibly be ready for this activity given the non-theoretical impetus for doing so.)  She referred her and her children to counseling.  She counted on the personal connections of a colleague to attempt to facilitate a more prompt oncology appointment.  She found a clinical trial that accepts Spanish-speaking patients.

Who is going to take care of her children?  How is she going to have hospice care without insurance?  How will she afford her pain medications?  Who will take care of her children?  NewFNP cannot imagine what would have become of her if her aunt had not raised her after her own mother died when newFNP was fourteen.  It wasn't the right time to bring this up with her patient today.

NewFNP doesn't know what else to do.  She cannot do much of anything.  She hates that.

Reform

Would it surprise anyone if newFNP were to say that she is a supporter of a public option for health care coverage?  Because she is.

NewFNP does not understand the arguments against public health coverage.  NewFNP thinks that Medicare is a pretty cool program -- certainly preferable to elderly people dying in the streets left and right.  And although the reimbursement isn't great and the prescription drug coverage leaves something to be desired, if newFNP's 94-year old grandma needs to go to the emergency room, it's covered.  If she needs to be evaluated for her hypertension, her doctor accepts her insurance -- her public insurance.

Another thing that oftentimes stumps newFNP is this vitriolic opposition to coverage for illegal immigrants.  Um, sorry to be the one to tell you, but this country spends a shitload of money on the medical care of illegal immigrants.  Lest anyone thinks that newFNP's clinic is full of native born Americans down on their luck, think the hell again.  A large proportion of newFNP's adult patients are living here illegally.  Some are applying for green cards and citizenship.  Others are ineligible.  For many, their children were born here.  By and large, the parents were not.

NewFNP is very mindful that she is spending taxpayer money when she is ordering tests, referring to specialists and trying her damnedest to take good care of her patient's complaint within the walls of her clinic.  But newFNP's time is well compensated -- those visits may be free to the patient but they are far from free.

In the absence of comprehensive and - let's be frank - rather harshly defined immigration reform, what exactly is the alternative?  

Not treating someone's active TB because they are illegal residents?  That makes little sense from a public health perspective as that adult living here illegally may spread TB to his child, who will in all likelihood go to a public school classroom where 30 other children may be exposed.  

Or not treating someone's diabetes so that they can present to the emergency room in DKA or blind or with a necrotic Charcot?  That's not going to save anyone any money and it sure as hell isn't going to prevent any suffering.

NewFNP doesn't know the answer.  But she knows that bankruptcy due to medical debt is fucked.  She knows that her patient today, a 40-something year old status post metastatic choriocarcinoma and a citizen, is scared to go to the emergency room for severe abdominal pain because she is already receiving daily phone calls over a $1500 outstanding debt.  

And she sure as hell knows that preventing an illness is far, far superior a plan from an economic, an emotional and a future-oriented perspective than is treating a chronic illness, amputating a leg, tracking down an outbreak of communicable disease or treating anything other than an emergency in an emergency department.  

Is there anyone at all protesting this plan who is uninsured?  Seriously -- anyone?  Have those who oppose a public option - even if it is only for citizens - ever met someone who suffered as a result of lack of insurance?  Are they utterly lacking in empathy?  

Not to be overly dramatic, but is this the America in which we want to live?