Take that, 911!

Yesterday, in the midst of uncontrolled hypertension and diabetes (see 'Rant'), the 7-year old patient in the next room was having dyspnea.

I swear, the kid looked fine when he walked into the clinic, but by the time I saw him in the room, his fever had shot up to 104.0, his 02 had dropped to 90-93% and he was sweating like a west coast native during a New England summer. The only thing missing was frizzy hair. In addition to these alarming findings, his eyes both got red and puffy. Not the way newFNP looks around grass and cats, but peri-orbitally he just looked wrong.

In addition to the fever, he also had rhonchi & wheezing so newFNP treated him to grape flavored Motrin, strapped him onto the nebulizer and put a cold pack behind his neck. In the back of my mind, I was wondering if I should treat him for the likely pneumonia or send his ass to the ED. And this is where the struggle of community health comes in.

The kid perked up, but still didn't seem A-OK to me. I was content to send him to the ED with his mom and three siblings, but they had no car. I asked her to call someone but no one was available to help her out. At this point, newFNP wasn't convinced that the kid needed an ambulance, but newFNP was also distinctly uncomfortable with sending him home.

As such, 911 was called to save the day. Of course, the kid looked super by the time the four paramedics arrived. As I recounted his tale, sounding like an idiot as always ("Um, I can't remember his BP - sorry"), the strapping, capable and tough paramedics looked upon newFNP as a nuisance, a burden, an embarassment to medical/nursing professionals everywhere.

Well, fuck them because the kid's mom called and told me that her son stopped breathing in the hospital. Now, I don't know if he de-satted or if he really stopped breathing, but he remains in the hospital as of now. All through the night I was wondering if I had over-reacted, but I am so thankful that I made the decision to send him.

Take that, hot paramedics! You think you know everything with your pecs and your biceps and your six-foot-three! Blow me.

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!

She don't lie, she don't lie, she don't lie.....

I'm sure that if there is one question on the minds of newFNP's readers, it is this:

What the hell is up with the coke nail?

You all know what I mean, right? It's the nasty-ass long pinkie nail that men sport. I have yet to see a lady rocking the coke nail. Aside from the male gender prevalence, these are the other demographic details I have amassed.

1) Men of all ages feel it is appropriate to advertise their love of the cocaine via a long manicured pinkie nail.
2) Men of varying cultural backgrounds find common ground in the coke nail. Does newFNP sense an opportunity for coalition building amongst cokeheads? The Million Pinkie Coke Nail March? Better wear protective eyewear!

NewFNP will take this opportunity to judge the pinkie nail. Judgement: foul. People need to head to the cokehead nail salon and chop off that disgusting talon. Ugh. Just seeing it grosses me out.

If anyone has insight into the coke nail phenomenon, please e-mail me at newfnp@gmail.com. I must gain understanding into this disturbing and widespread occurrence. Is there an alternative explanation? Is it just to clean one's ears?

Help me understand this frightening trend. I beg of you, help.

Follow-up visit

So, my yeast ear lady came back today. Sure enough, the culture showed budding yeasts. And for those who are keeping track, Diflucan does in fact work on extra-vaginal candida infections.

But here is the crazy part. My patient was not only rocking otic yeast.

As I skillfully manipulated the otoscope to visualize the canal, I perceived an eerie green glow. Did she have Kryptonite in her ear? Did she melt some Play-Doh in there?

In fact, no. She had a pseudomonas aeruginosa. And Cipro Otic costs approximately $80. How it sucks to be uninsured with an uncommon gram-negative otitis externa.

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?

When TV is the cure

Cold & flu season has struck my clinic and, as newFNP has up to date information on the latest and greatest treatment guidelines, I would like to offer these words of advice to all of the patients streaming in and out of my clinic with body aches, fever and malaise: stay the fuck home. Watch some Daily Shows that you have TiVo'd. Check out reruns of CHiPs or Dos Mujeres, Un Camino. For the love of god, sleep - but do not expose me, my staff and my patients with pneumonia, diabetes and asthma to whatever you have brewing! And quit asking me for antibiotics. You're not getting any.

It's not that newFNP doesn't sympathize with how crappy one feels when one has the flu. It's just that a guiding principle of public health is to reduce one's exposure to potentially hazardous conditions. Your partner's herpes are acting up? I can't think of a better time to abstain. Granny has a touch of the TB? Don't share a non-ventilated close space with her.

But, you see, this goes both ways. If you know that your penis is leaking green discharge and you need to take a percocet in order to pee, don't hit up your special lady or fella for sweet lovin'. And if you are fluish, please have the courtesy of limiting your exposure to others. Sure, your family will suffer, but does that mean the entire community must as well?

Oh, and if your penis is leaky, that is a perfect time to hit up the clinic for antibiotics. We'd gladly give you a Rocephin injection! With Lidocaine and everything.

But does it itch?

Ear pain. We've all had it, but I'd hazard a guess that we haven't all had the symptoms one patient was experiencing today. Last month, she was treated for otitis externa and has been using cortisporin otic drops. Steroid-containing drops. Her pain was intensifying over the past three days so she returned for follow-up care. In addition to her otalgia, she also had tender pre-auricular lymphadenopathy. Her past medical history is negative for diabetes, FYI.

Good ear looks good. Textbook, one might say. Affected ear on the other hand... I carefully looked in her ear and thought, "Now, if I were looking in a vagina, I would be quite certain that I was seeing yeast." Now, I do not come home to peruse Gray's Anatomy every evening, but I am confident that I know an ear from a vagina. But yeast? In the ear? Another first for newFNP. It was all I could do not to laugh as I used a vaginal wet mount swab to grab a culture of the ear funk. Ah, improv.

I treated her with Diflucan under the philosophy of what's good for the south is good for the north. I can't wait to get that ear wet mount back.

Oh, the learning curve

Did we learn about labs in school? I don't think so. I think that there should be an elective about lab result interpretation. Mind you, newFNP attended a well-respected institution, but has somehow made her way through without having a good understanding of lab results. Don't think for a minute that I can't interpret a CBC, because I can, but when you start throwing a jacked kidney my way, I am flat out lost. When there are too many numbers in the 'abnormal' column, my eyes glaze over as though I am back in C.O.C.

Case in point. I had a patient last week who was an interesting looking little guy. 65 years old. First name: Latino. Last name: Asian. Not a common combination in my 'hood, but stranger unions have certainly happened. Skin was a little yellow looking, belly was really round. Maybe I should have picked up on that, but if I stopped to really consider every weird-looking, rotund patient who crosses my path, I would have no time to peruse the internet for Sigersons and flattering Theory trousers.

My patient also had a very chatty wife who accompanied him to his physical and freqently interjected her own tales of health woes throughout his exam. NewFNP can only handle so many distractions and annoying chatty wife was throwing me off my game.

Long story short, Mr. Latino Asian likes to drink. Hell, newFNP likes to drink, but not like this guy! I drew his labs and got this, amongst many other abnormal values, back:

Albumin 2.6 (3.8-5.0) So - low, right?
Bilirubin 6.5 (0.1 - 1.5) Let's call that one 'elevated.'
AST 113 (1-45) Remember - Alcohol, Statins, Tylenol
ALT 56 (1-55) Ding ding! Most normal lab value goes to ALT!!

Another provider took a nano-second glance at the labs and said "Oh, AST 2 times the ALT is pathognomonic for alcoholism." She then glanced at him and said, "He is clearly cirrhotic." He is??? Well, shit. If I would have known it was so obvious...

The problem is that many things need to be so flagrantly obvious. Your blood pressure 210/105? Buddy, you are one hypertensive motherfucker. Blood sugar in the 600's? I'll lay my money on diabetes.

But other seemingly obvious diagnoses escape me, to say nothing of the not-so obvious diagnoses.

On the bright side, I really feel like I have my charting/prescription signature nailed.

"I" statements

We are all taught to speak to patients in "I" statements, especially when confronting something that is potentially uncomfortable. This may include, "I notice that you have bruises in the shape of fingers" or "I see that you weigh 498 pounds" or "I can see that you are upset by your gonorrhea infection and need for a painful Rocephin injection."

However, sometimes newFNP's "I" statements escape her. This week, it was because I wasn't sure what I was (not) seeing and feeling. When I was in school, I had a similar experience in which a patient, upon whom I was gearing up to perform a DRE, assumed the position, thereby exposing her tail. "I see you have a shaggy tail. Has that always been there?" No, no - I didn't say that, but any sensitive statement I may have been able to come up with was vanquished by the magnitude of my shock. Why didn't they tell me in Advanced Health Assessment that I may happen upon a tail? I was ill-prepared.

I was also ill-prepared for my 36-year old father of three with tiny, hard testicles as well. Now, although newFNP does not possess said equipment, she has once or twice been familiar with those who do *and* has seen enough in the clinical context to know that they should be more like matzo balls than walnuts. So, what was I to say?

"I notice that your testicles are like raisins. Were they ever prune-like?"

"I feel that your testicles are firm like marbles... and not much bigger. Were they ever more like Everlasting Gobstoppers - the big ones?"

"I see that your testicles are essentially non-existant. Do you really have three children?"

See? It's hard to have good "I" statements on the fly. Part of the reason it was difficult is because I was uncomfortable telling this gent that his balls were weird. Is there a guy out there who wants to hear that? In Spanish. In my crappy-assed Spanish.

"Sus testiculos son demasiado locos." Bad, bad newFNP. Must learn sensitive Spanish!

May-December

In the spirit of "Shopgirl," in which a fresh, vibrant Claire Danes dates a geriatric Steve Martin, I offer this thought. It's not only the aging Hollywood set who enjoy a youthful romp with a partner half their age. Not at all. This week, a 76-year old patient told me that he had 10 children, the youngest of whom was an astonishing 5 years old. A quick mathematical calculation told me that his wife must not be his age. Yes, my patient's first wife died when she was 70. I don't think that the mourning period was a long one before he nabbed his currently 38-year old wife.

When I think of dating someone nearly 40 years my senior, I think of one thing and one thing only: money. Now, I could be wrong, but my sense is that this 38-year old woman is not rolling in an A8, nor is she sporting a Harry Winston, nor is she head to toe in D&G. But even if the hottest rich 70-year old in the world wanted to date me, he would still be 70. Whatever works for my patients is cool with me, but I am, quite frankly, grossed out by the thought of shagging a grandpa. Do you think she has to inject his hips with cortisone so that he can lay the sweet moves on her?

Guh-ross.

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?

Melting

NewFNP is somewhat cynical. Dry. You know the type. Not someone easily moved by cuteness.

However, newFNP is not made of stone. Today a little girl, around age 7, was at the clinic with her mom, who had an appointment. After I had finished the appointment, which involved tears, labs, referrals and the ED, the little girl grabbed my hand in hers, kissed it and said, "Thank you for helping my mommy."

It was the best moment of my life as newFNP.

One for you, one for me

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Social history

There are certain questions that I have not once asked any of my health care providers. These questions include:

1) Are you married or single?
2) Do you have any kids?
2a) Why not?

My patients, however, ask me these questions with astonishing frequency. I'm talking daily to multiple times daily. On Friday, I'm quite certain that a record was set. If I had to hazard a guess, I'd say that fully 40-50% of my patients asked one or more of the previous questions. One older gent went on to ask, "What kind of men do you like: Mexican or American?"

He then offered this little bit of dating advice. "You know what you should do?" he said. "Go to dances." This is the same exact advice that my grandmother gives me, wistfully thinking back to the WW2 era dances, one of which she attended and met my grandfather. I told him what I tell her: I don't like dancing. Why would I want to meet someone who does? I'm sure that I can find many ways to disappoint the man of my dreams and I don't need to add fuel to the fire with the ole "I like to dance" bait & switch routine. I like to read. I like to sit on my couch, drink French Roast, and read. I meet a disappointing number of hot, smart, funny guys (n=0) conducting this activity.

So, yes, my patients frequently ask me about my personal life. And, going against what my professors might counsel, I answer them - mostly. I don't tell them that I don't think I want kids because my sense it that is akin to telling them that tortillas aren't breakfast food for me, or that I have no interest in soccer (or any other sport except mine for that matter). I think it's appropriate to share to the extent we are comfortable with our patients. Part of why I am an NP is to remove barriers to patient care. I hope that my being a person and not just a fucking hot-ass girl in a white coat will facilitate that. I want to build relationships with my patients in an effort to keep them healthy and to keep them satisfied with the care they receive at our clinic.

Plus, it's like having a nice Jewish family, meddling in my personal life, right here in the midst of my Latino patient population. L'chaim!

Diamonds

In school, we often receive 'pearls' about patient care. NewFNP is more of a diamond type of girl. A little flashier, a little less 1950's housewife. So I'll offer a couple of diamonds from my week.

1 carat: When you have a patient with a low hemoglobin (see 'I hate it when I'm stupid'), re-check the measuremrent in no more than a week. One reading doesn't tell you if they are actively bleeding, but if the result drops then you know that something is rotten in Denmark. Sure, this seems utterly common-sensical, but sometimes when you are new, even the most pedestrian of logical thought processes eludes you. I'm sure you all smarter than me, however....

2 carats: I am screening so frequently for depression and having so many patients disclose that they are depressed. That is not the diamond; just hang on a second. The reason I am screening so much is that I realized that a lot lot lot of my patients had non-specific complaints and an affect that bugged the shit out of me. Now, newFNP understands that that is neither replicable nor sensitive, but the truth smarts at times. So these patients bug, baby, bug. I can't find anything wrong with them, which definitely has the potential to be chalked up to my new-ness. However, I started to think that the headache, back pain, abdominal pain and bone pain, coupled with 10+ annoyingness might be something else. I swear, I pose the question, "Do you think you are depressed?" and watch out! Grab your galoshes and rain caps because the water works start. Then, of course, I feel like a big fucking asshole for my insensitivity and for being annoyed with them in the first place. *I* was the problem, after all, or at least part of the problem. It did, however, reinforce that I need to truly be aware of mental as well as physical health screening *and* that I need to need to trust my instincts.

No more diamonds! Except for Boston FNP, who should check out "The Girl's Attractive" by Diamond Nights.

Picky evolution

NewFNP is no proponent of intelligent design. Anyone who has taken a college-level biology class can understand why when you think back to the markings on animals, moths, insects, etc. Others may remember that from high school, but newFNP had biology 1st period and was no fan of 7:50AM classes. It's true, newFNP was a big 1st period ditcher. Anyway...

One of my non-scientific proofs of the theory of evolution is that I understand the desire to pick. Have we all seen the PBS shows in which the mommy gorilla picks crap off of the baby gorilla? I loooooooove picking. It's gross, but true.

I began to understand the process of natural selection and its relationship to picking this week in clinic. This understanding has made me think twice about my love affair with the pick. Here is a mathematical equation to explain what I saw this week:

folliculitis + (machinist + greasy, dirty hands) + picking = 2(abscess)

And the funny thing... what did he call it? A rash. Noooo, not a rash my friend. A pus pocket, a purulence pond, a perilous post-picking problem.

Must. Keep. Hands. Off. Blemishes. Bumps. Et cetera.

Ayyyyy me duele!!

Culture. We all have it. In mine, stoicism in the face of pain - emotional or physical - is valued. I'm not saying that's right, I'm just laying it out there. Apparently, an ever-elusive perfect weight is valued as well as newFNP's family always has a comment about weight during any visit - too much, too little, but not-as-of-yet just right. Anyway, internal demons aside, newFNP is one to grin and bear it, pull herself up by her bootstraps - bootstraps which will one day bear the Prada insignia if all goes well.

This cultural bias and placement makes it exceedingly difficult for newFNP to stomach the (perceived) histrionics of pain during exam. The vocalization of "Ayyyyyy, me duele.... aqui, ayyyy me duele!! Doctora, me duele!!! Ayyyyy, dios mio, me duele!!" It makes me crazy. I don't doubt that it hurts, but I would have to be carrying my own detached arm to the doctor to complain half as much as these women do. A good fashionista pal pointed out that perhaps some of these women have no other place to vent their pain - a good hypothesis, I believe.

Cultural bias takes on other forms as well. Today, a 40-year old patient came in for a pap. She had sex last night - no condom. Generally, no condom = no pap, but her case was different. This woman has had sex virtually every day for the past 26 years with her husband, whether she wanted to or not. According to her, she "rarely" wants to. According to him, it's her responsibility. Even though she complies with this, again, nearly daily activity, her husband has had many extra-marital relationships and has, according to my patient, transmitted chlamydia, gonorrhea, herpes and pubic lice to her throughout the course of their relationship.

How is that for insult to injury? Sexually transmitted infections through forced sex. Incidentally, she denies IPV. Hmmm..... can you see where newFNP's culture is sneaking in?

I asked her if she thought it was okay for her to have sex with her husband when she didn't want to. She responded, "No se." If she doesn't know, how am I supposed to know? I know what the answer is for me, but is this a universal truth or a newFNP truth? Her affect and her tears told me what she really believes, but I could only offer her the tools available to us: our counselor.

I am so glad I got to come home to my apartment, no abuse, maple yogurt and Boston Legal on the tube. I wonder what her night will be like.

Incidentally, in the area where my clinic is located, I have noticed a cultural value of slow-assed fucking driving. Ayyyyyyy, me duele, the slow drivers. Mueve!

I hate it when I'm stupid

I think that when I'm overwhelmed, I have that whole "forest through the trees" problem. I saw a patient this week (several times) who I diagnosed with Type 2 Diabetes. Her blood sugars were in the 3- and 400's. I was diligently attempting to decrease this number when I noticed that she also had a Hgb level of 6.3. I provided the following to her:

• diabetes education regarding meds, sequelae, dietary changes, exercise
• prescriptions for appropriate meds and insulin in the office
• Ferrous sulfate 325 mg/day
• referral for colonoscopy
• stool cards x3

And, in all of that, I also provided utterly inadequate care. Why? I didn't get a fucking CBC! How did I miss that? Total cholesterol? Check. Hgb A1c? Check. CBC? Nope, not so much. Ugh! Why am I still a jackass? The beauty is that every time I feel like an ass, I know that the shame of missing something so easy will cause me to never make that rookie mistake again. And I am a rookie, after all. I just don't like to play like one.

Achy Breaky Heart

A crazy thing happened today. I saw the most patients I have ever seen in a single day (n = 28) and I left the clinic at 5:00 PM on the nose. It was divine. I am in a state of joy bordering on beatitude.

I did, however, send a patient to the emergency room. I like to have both the calm and the storm, I guess. Here is why this man had a ride with the paramedics. He had chest pain, dyspnea (worse when supine, so I guess technically it was orthopnea) and had diagnosed left-sided heart failure last year that resulted in him receiving a pacemaker. His father died from heart failure at age 54. And did I mention that, despite treatment with 80mg TID of Lasix, he had urinated exactly once (4 ounces – he actually measured) in 48 hours?

Now, I must confess that I partially sent him because I was scared, the only provider in the office this afternoon, and I knew that his history and symptoms were both serious and beyond my ability to care for. I think that it was the right decision. He was overweight and his exam was unremarkable, but as I’ve previously mentioned, ausculatory exams on obese persons are exceedingly difficult. Did I hear crackles? I did not. Nor did I hear normal breath sounds; I heard faint breath sounds and faint heart sounds. His abdomen was huge. Was he holding fluid in there? I don’t know, but the doctors at the emergency room will.

For those students/new practitioners who are familiar with the lower extremity edema/DOE/chest pain presentation of heart failure, please allow me to point out that this picture often points to right-sided failure. Left-sided HF is sneakier. I was too freaked out to think about that until the paramedic mentioned it, leaving me to feel like a huge jackass. Whatever – my ego will survive and I am the wiser for it.

Here are some tidbits to refresh and/or inform:

Signs of HF include:
DOE/PND/orthopnea
Cough with or without frothy sputum (yeah – gross)
Abdominal pain +/- nausea
Constipation (who knew??)
Exercise intolerance (I’d hazard a guess that 90% of my patients have this as they never exercise)

Symptoms of HF include:
Fine crackles, generally bibasilar
S3
Edema
JVD
Tachycardia
Hepatomegaly
Pallor or cyanosis

However, Uphold & Graham point out that “[in] left-ventricular systolic dysfunction, signs and symptoms are not reliable indicators or cardiac functioning; patients with severely impaired ventricular performance may be completely asymptomatic until they overexert themselves…” Thus, the ED visit today.

Which reminds me… the paramedic asked me, as I was standing there feeling like a buffoon, if any of the patient’s medications were constipating. A) I don’t fucking know for certain but probably not and B) constipated or not, homeboy has essentially not taken a leak in 2 days and has both a personal and family history of cardiac disease. Can we deal with the poop later, please? When I’m thinking of priorities, it goes something like this:
1) heart failure
2) poop

Twenty-eight patients. I think my days on easy street will be coming to an end. I exceeded my goal – set by the clinic manager - of 22-25 patients/day. Crap.

I Need a Hand Job

NewFNP is no germophobe, unlike a certain successful law clerk I know, but when one sees 22 patients a day, 50% of whom have complaints that include vomiting, diarrhea, cough and congestion, one washes one's hands multiple times per day. I generally wash before each patient, after some patients, before and after eating, and after using the bathroom. That is approximately 30 - 40 washes per 9 hour day.

My hands are wrecked. Dry, cracked, raggedy-cuticle messes!

I use the blue spa lotion before going to bed at night. I use it liberally, but it can't compete with the multiple daily hand-washing assaults. I thought I was leaving my love affair with Vaseline on the east coast when I left, but I was sorely mistaken.

yakkity yak

On the way to work today, I was almost decapitated by a red light runner. I had a fleeting concern that my near death experience would shape the remainder of my day. After my first patient, I was considering a career in the psychic arts.

As many of you know, nasty viral infections come in waves. Epidemiologically speaking, one might refer to these as mini-epidemics. The beginning of the school year is a perfect time for viral illnesses to fester and spread. When I saw my ill 4-year old patient today, I was expecting a routine "cough, congestion" exam. That is precisely what I got until she refused to let me examine her throat.

In the interest of full disclosure (not that newFNP is at all interested in that given the nature of this blog), I should note that it is frigging frustrating to me when a kid refuses to let me look in his or her throat. An ear, I understand, but the damned throat. I don't even do anything. It's a hands-off proposition!

So Miss Cough & Cold gave me a big middle finger to the throat exam. "Fine," I figured. I just sat back on my rolling stool and figured that she would come around after some Q.T., crying to her mom. I maintain that my plan was not without merit, but the subsequent events were entirely unexpected and knocked my "wait it out" plan on its ass.

This little girl was not joking about the cough. In fact, she coughed herself right into a spell of vomiting. At 8:45 - after I had nearly escaped death and dismemberment at the hands of a crazed woman in a minivan. I grabbed an emesis basin and held it to her face. She was still crying, still coughing, and still puking. I turned and set the basin down in order to grab a paper towel when I heard the all-too-telling sounds of imminent barfing. I quickly grabbed the basin, with a small amount of vomit still in the bottom, and rushed back to her side.

Now, I have no idea how it happened and it was completely accidental, but somehow I slipped or her mom hit my hand. I do not know what in the hell happened, but the next thing I knew, this little girl had her own vomit dripping down her forehead and off of her nose. And I thought she was crying before the exam and the vomiting.

Fucking hell. What a day.

The Crying Game

It happened. I made a patient cry today. In fact, always the over-achiever, I made a patient and her mother cry.

It is my nightmare to tell a patient that they are overweight. I know that they know they are overweight. It's my assumption that most people don't want to be overweight. It would be easier for me to tell my grandma that she had herpes. That is how little I want to discuss weight.

Even as I shoveled lobster tail, filet mignon, cosmopolitans and more cosmopolitans into my trap this weekend, I was hoping to fit into my cute skinny pants at work this week, to say nothing of the tight-ass airplane seat. Fuck coach.

Anywho, it's my further assumption that there are exceedingly few adolescent girls who want to be overweight. Today, one happened to cross my path. She was sweet, middle school aged, 182 pounds, hypertensive and sporting a smooth, velvety acanthosis nigricans necklace.

And I had to tell her that her weight was the problem, that it was hurting her and that it would continue to hurt her if we didn't make changes. Of course, I explained why excess cardiac strain is dangerous and why diabetes is a serious illness. I told her how I could help her and how she could help herself. I never said "fat," but I cannot believe that she didn't hear that vicious, devastating word.

I told her no more Hot Cheetos, no more pan dulce, no more soda, no more unhealthy foods. I told her mom that she must not have that shit in the house (not verbatim).

And even though I told this girl that I was there to help her, that I wasn't telling her that she was bad and that I absolutely knew how much it sucked to have this conversation, I felt like a complete jackhole. And through it all, I knew that it was utterly incumbent upon me to tell her these difficult things. I'll see her in 2 weeks, food diary in hand.

Here is how research methods came in handy during this interaction. I utilized a verbal Likert Scale in the form of: On a scale of 1 to 10, how much do you hate me right now? She smiled.

My worst nightmare

When new FNP considered what she least wanted to see in clinical practice, it was this: dizziness ("mareos") in Spanish. Dizziness throws me off in any language. English, Pakistani, Hebrew? It all sounds the same to me when the subject is dizziness. I realized that this was my nightmare a couple of months ago when an FNP friend told me that she conducted the Dix-Hallpike test on a Spanish-speaking patient during a blackout. I thought to myself, "What the fuck?!?!" Thankfully, the lights were on today, but nobody was home in my pea brain. We got it all figured out, but man, oh man do I ever hate vertigo.

On the STI front, I saw yet another infection today. So far, STIs to date include herpes, PID and - today's entree - warts. Yesterday, another provider had a patient with gonorrhea AND high-risk HPV. Every person who I have encountered who was diagnosed with an STI had a partner with whom they were believed to be monogamous. Now, new FNP is a single lady and has, in her day, made some very unfortunate decisions regarding dating. Am I naive to think that they were just assholes and not big fat cheaters as well? I know that I haven't dated my Mark Darcy, but I hope that I haven't dated only Daniel Cleavers.

A common complaint in my clinic is "bone pain." It generally refers to whole body aching. I am a believer that mental/emotional stress has physical consequences and suspect the poverty and its associated difficulties play a role in my patients having this pain. However, it takes time to elicit the important social factors in people's lives. Today I saw a woman with the bone pain and she had nothing, nothing, nothing wrong with her on exam. I was already frustrated when I walked into her room and even more so when I saw her chief complaint. I do appreciate how badly that sounds, but new FNP has her good days and her bad days, OK? I suspected depression initially, but didn't feel like jumping to that conclusion without sussing out the physical complaint. Well, I felt like an ever bigger shit when I realized the extent of her depression. "Hi, I'm new FNP and I'm a completely insensitive prick."

It's good that new FNP is visiting some of her best friends this weekend. I need a break. And a glass (bottle, fridge-full) of wine. And someone to kiss, but not a Daniel Cleaver.

Balance

One of new FNP's favorite author's, S.R., read from his new book today at a nearby venue. I was introduced to him while in grad school and fell for him instantly. His writing made him incredibly attractive although, to be honest, S.R. is not a handsome man. However, new FNP rolls with the philosophy that smart is sexy. Genius, though, is intoxicating and I am in love with him all over again.

It was wonderful to have nurtured this part of my life.

Plus, he spoke about the book the new FNP has snobbishly dismissed as trash passing as literature: The DaVinci Code. He made the comparison of hamburger versus haute cuisine and opined, "Dan Brown is the McDonalds of literature." Exactly. He did acknowledge, however, that even he craves a Big Mac every once in a while.

New FNP + S.R. forever.

A day of firsts

Part One:
One might think that someone with suspected peritonsillar abscess would present with something akin to trench mouth. Like "Yuck Mouth" from the Schoolhouse Rocks days. One would, apparently, be wrong. My patient today told me that she had been having R-sided ear and throat pain of about one week's duration. Her throat pain was such that swallowing was excruciating.

Her exam went like this. Normal. Normal. Normal. Hmm.....

Her pharynx was distictly asymmetrical. No history of surgeries or traumas to the oropharynx. So much for just another URI. I looked again. And then again. The presentation hadn't changed. Inflamed and asymmetrical. And away to the ED she went.

Lesson: it's true that all of the "normals" inform your judgement when there is a physical exam finding that is decidedly abnormal.

Part Two:
My patient was describing to me what sounded like a UTI. Dysuria, frequency, urgency. The triumverate. But there was also the little issue of dyspareunia x 1 month. And something else that seemed significant at the time but escaped me now. Ah, yes - lower abdominal pain.

Now, new FNP is not unaware of the severity of PID and is keenly aware of needing a low index of suspicion in order to initiate treatment.

Throw in a little cervical motion tenderness (OK, a lot of CMT) and some suprapubic pain on exam and voila - I ordered my first Rocephin IM. No quinolones with breastfeeding, so she had to endure the torture of the injection, to say absolutely nothing of the significance of the diagnosis. Plus a 14-day course of Flagyl and some Doxy for her partner.

It felt so shitty to tell her that there is a very strong correlation between sexual intercourse and PID and, although I couldn't be certain of the diagnosis based on exam, I had to treat her given the potential for sequelae. Is it an STD? Is it just an ascent of normal vaginal flora? It depends and I'll probably never know what it is for her. For those interested, outpatient PID treatment in non-pregnant/breastfeeding patients consists of 500 mg of Flagyl BID x 2 weeks AND ofloxacin 400 mg BID x 2 weeks OR levofloxacin 500 mg QD. Some resources say 125 mg of IM Rocephin is an alternative to the quinolones; others say 250 mg. I gave 250 mg - reconstituted with 1mL of lidocaine to help ease the injection pain. PLUS partner treatment PLUS 2 weeks of abstinence or condoms until the infection clears. The CDC has really good treatment guidelines inline at http://www.cdc.gov/.

Lesson: The power we hold as practitioners is quite notable, worth reflecting upon and is essential to acknowledge as we approach our encounters. As I keep saying, I currently have the ability to take time to be with my patients during difficult times. I hope that I continue to make this a priority as I am expected to see more patients.

Week-end round up

As some of you may remember, I cultured a "rash" for herpes virus about a week ago. Yeah, it's positive. Time to learn the Spanish for "no, there is no other way that this is transmitted." OK, I actually know how to say that, but all of the other stuff I envision that appointment will entail is another story.

Physical exam finding of the week:
Inguinal hernia the size of my forearm. Reducible, thankfully. Lay the dude supine and bye-bye hernia. Stand up and watch out! How has he been walking around with this for TWO years?

Lab result of the week:
Triglycerides: 1755 (not a typo) reference range: <150. Hey buddy, how's that pancreas feeling?

A little word on obesity. As all health practitioners know, obesity exerts its deleterious health effects on virtually every body system. It also makes the physical exam much harder. I can barely palpate a liver on a good day and on a regular-sized patient. Give me an overweight abdomen and I will most definitely miss hepatomegaly. Are you a very overweight person in early respiraory distress? My auscultation will suffer because even my sweet-ass cardiology stethoscope won't be able to make it through the excess tissue to hear the lungs. And, without going into detail, I will just note that the pelvic exam on an obese woman is exceedingly difficult.

Pelvic exam tip: Shy cervix? If it's hiding from you, have the woman grab her knees and pull her legs up toward her chest. Poof! Magical cervix eliciting maneuver. I can't imagine what in the hell the patient is thinking with that one, but you've gotta get the cervix to get a good pap test!

NewFNP recognizes that there are many ways to care for oneself, which is why she got a facial today (and a bikini wax, but the wax was decidedly not relaxing - Boston FNP, you know what I'm talking about). The esthetician is a woman I went to for a few years before I left to attend the MSN program. She remembered so much about my life, about my family. It made me realize the importance of the personal connection in our work encounters. True, she was practically my gynecologist today and that is pretty damned personal. But I thought to myself that I wanted to reinforce my commitment to learning about the lives of my patients so that I can support them in more than their illness management. Which, in turn, reinforced that 15-minute appointments suck balls!

Yesterday, for the first time, I loved my job. And I started to feel like I was good at it.

I am so naive

New FNP likes to think of herself as street savvy, but let's be honest here. Although she can roll like a P.I.M.P., she has spent the majority of 1999-2005 in graduate school. That is not street at all. That is straight up nerd.

So when an 18-year old with 2 gunshot wound scars to the arm tells new FNP that she was shot last year while at an outdoor BBQ, the interaction goes a little like this:

newFNP (shocked): Ohmigod, that's awful. Was it a drive by shooting?

Client (bored): Yeah.

newFNP: Did they catch the person who shot you?

Client: Yeah.

newFNP: Did they go to jail?

Client: Naaahhh, not jail....

newFNP at this point realizes that a little bit of street justice has taken place. And changes the subject.

But being the committed newFNP that she is, newFNP did teach this young woman how to conduct SBE even with a bunk left arm, s/p GSW and all. Adaptive education, baby. Word.

I'm no nephrologist

Kidneys confuse new FNP. One professor taught us about them using an M&M analogy which seemed to work for other people, but never quite sat with me. New FNP didn't totally care that she was missing something because we got to eat M&M's (big boy and little boy), which was stupendous. But here new FNP sits, listening to Death Cab and wondering about kidneys, ACE Inhibitors and just having an overall "what the fuck" moment.

So, the major messages new FNP has cemented about ACE Inhibitors is that A) they give you a cough; B) diabetics with microalbuminuria need them; C) check the K+ and; D they are a big no-no in renal disease, specifically bilateral renal artery stenosis. Even thinking about this at 9:00 PM gives me hives. What new FNP didn't understand this AM when she saw her 1st patient of the day was why ACE I's protect kidneys in one instance yet harm them even more in another. Well, new FNP has the answer for those interested in specializing in nephrology - although why, why, why would you?

Anyway, diabetic nephropathy is likely prevented with an ACE as a result of the decreased glomerular efferent arteriolar resistance (can we call it GEAR??) and a reduction in intra-glomerular capillary pressure, thereby preserving GFR, improving renal hemodynamics and diminishing proteinuria. In renal artery stenosis, the vasodilating effect of the ACE prevents the kidney from maintaining perfusion, thus leading to ischemia. This is all from my textbook, by the way. I still don't totally understand, but if I try to picture a stenotic renal artery, I can begin to get it a little more. New FNP is open to taking help from students of the kidney. Please, e-mail away.

Seriously.

To do:

• add pre-, intra-, and post-renal causes of renal dysfunction to the "to learn" list. What new FNP really needs to learn where a Sigerson Morrison store is in the town, because when new FNP is stressed, she needs cute shoes.

New FNP saw 16 patients today and, amazingly, was not utterly destroyed at the end of the day. Poco a poco, as we say in the clinic when we are talking about dietary and lifestyle change at every flippin' diabetes visit. Little by little.

double down

Part of what you learn in school is luck. Did you see a patient with an aortic aneurysm? If so, you're unlikely to forget how it presents. If you read about it and learned about its clinical presentation, well, that's just not as good. At least for new FNP. So today I saw what I am almost certain was herpes.

Grouped vesicles on an erythematous base? Check.

History of similar outbreaks that resolve without treatment? Check.

Discomfort? Check.

Genitals? Check.

Thankfully, we have the requisite derm picture book in the office and I was able to compare my mental picture of the lesion with the book. It matched. The instant I saw it on the patient, I thought "herpes," but I just didn't trust my gut. I'll be interested (in an utterly academic manner) to see what the viral culture shows. Let's just say that the counseling was difficult today and, of course, it was in Spanish.

Did you all see periorbital cellulitis in your clinical rotations? Well I didn't, but I sure read about it and understood its severity. That was why I was freaked as shit to see a big ole swollen eye today. I have seen some conjunctivitis in my day, but I've never seen something that looked like the trailer from that movie "Hitch" or whatever it's called with Will Smith. Well, this kid's eye was sw-ol-len! As I did with most patients today (it was one of those days), I consulted. I guess sometimes eyes just swell from allergic/viral/bacterial conditions. Thus, the "-itis." BTW, of course new FNP examined this kid's EOMs and pupillary response, lest anyone think new FNP is a total schmuck. All normal.

And finally, the rash. New FNP is very sensitive to the allergic reaction as she has had several in her day. The freaky thing is when all of your Magnum P.I. skills fail to elicit the etiology of the rash. Thankfully, there was no respiratory involvement so a little diphenhydramine should do the trick. Until next time, which is the part I don't like.

Let's see - on my list of shit to learn today is:

ferrous sulfate therapy - infants
uterine prolapse (asymptomatic)
how to keep my shit together
spanish

This list is not all-inclusive, but new FNP is tired and has had a glass - OK, two glasses - of wine tonight. Ah, sweet, inviting, new Spring Air mattress... it has been 24 hours and I need you!

Day 8

It is the little things that will throw off your day.

For instance, new FNP had a patient today who has diagnosed diabetes but has never been seen in our clinic. She wants to begin receiving care with us, which is great. But she had a 15-minute appointment and no medical records regarding prior care. And her blood sugar was 356 in the office. Granted, it's no 500, but it's certainly not helping her at all to be cruising around with sugar in the 300's. Can I get a hell yeah?

Another example that new FNP experienced today was the problem of patient flow. Now, new FNP was the only clinician for a few hours this morning, which is theoretically fine as the other provider was accessible. New FNP felt OK until 8:45 and her 8:30 patient wasn't in the room. Ditto for 9:00. All it takes is a patient not being moved through the clinic fast enough to get you 30 minutes behind before you have even started. By the time new FNP was rescued, she was so frazzled that her Spanish was unintelligible and her hair was frizzy. How unbecoming.

Another thing that might throw off your day is the kid with the 104.2 fever. This kid had been seen by new FNP 2 days ago and by another provider last week. At the prior week's visit, he received an antibiotic. New FNP did not prescibe an antibiotic 2 days ago because A) he had just had one and B) there was no obvious source of infection. He did, however, have a 103.1 degree fever that responded to Tylenol in the office. So, new FNP let the kid leave with Tylenol and strict instructions for returning or going to the ED. So when he rolled in this afternoon with his high temp and still no obvious infection, new FNP was frustrated and a little scared.

Upon a closer read of the chart, the kid had been seen by a few providers for a total of 8 times in the past 3 months. Hmm.... let's go for the urine cx and the CBC. Oh wait, no, let's lay on the floor kicking and crying because you don't want your blood drawn. Now, new FNP is not callous and she understands that little kids are scared of needles. But she also understands the significance of a high fever of unknown origin. So, after consultation, she writes the note for the ED consult.

It's now 5:15 PM.

Let me just say the the social issues within the family made for a very, extremely, unusually difficult experience. It wasn't abuse or neglect - nothing like that. It was just that their lives are complicated, that they don't have money, a car, a cell phone, or support.

That last part is true of many of the patients I see. I hope that all of you student NPs and other new NPs are screening for depression. I don't always know what to do for the patient, but they deserve to have our concern. We can't help if we don't ask, right?

New FNP left the clinic around 6. The last 45 minutes were spent negotiating with a 5-year old and trying to figure out how in the world to support this kid's mom, impress upon the dad the seriousness of the situation and not cry myself.

I saw 17 patients today. I realized that I like seeing patients, but I fucking hate not knowing how to help or what to do. And I hate to be behind.

time with patients

The one thing that is so great about being in school is having plenty of time to spend with your patients, to engage them about their lives and to really attempt to develop workable solutions to their health problems. That just isn't feasible in community health. It's all about the numbers. It's such a rip off that you are held to this standard of a patient each 15 minutes, but are also held to a standard regarding patient outcomes. A perfect example of this is Hgb A1C levels in diabetics. Our clinic measures them as a component of a grant collaborative (as well as for regular care, of course). As we all know, achieving glycemic control is extremely difficult. It's more difficult when your patients don't have SBGM equipment and even more difficult when all of your counseling is in crappy Spanish. Now add on an inadequate amount of time. It's bad news.

Today, I had a sort of difficult pelvic exam on a 29 year-old. It was one of those exams during which the cervix is elusive, hiding from you. It took me three times of inserting the speculum to find it. I know that this is extremely lame and it must have been totally hideous for the patient. But I apologized and acknowledged how difficult it must have been for her. And do you know what? After the exam, she thanked me for being compassionate and understanding. Now that goes to show that a little humanity is a great help in the clinical encounter. I know that it is idealistic and that providers are strapped for time, but it took me a matter of seconds to acknowledge what I knew to be difficult and it made a big difference to her.

I don't think we should be made to see 30 patients per day. I think that both patients and providers suffer with that workload. And I haven't even seen that many yet!

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.

Triplets

When newFNP was in school, she did a pediatric rotation at a community health clinic which conducted "double" physicals when there were 2 kids in a family who needed care. One such visit was with identical 11-year old twins who also had similar names. And dressed semi-alike. One had a heart murmur that she picked up on exam. She knew which kid it was because she had written what each kid was wearing on their respective encounter forms. These kids looked cloned, they were so similar in appearance. That, friends, was frigging junior varsity. Today, newFNP had 4-year old triplets. Again with the cloned appearance. One with asthma and borderline anemia, another with a high lead because of the chili candies he likes and the other - shit - she can't even remember the other. It sounded like Romper Room in the exam room. All of the kids were small, likely as a result of their prematurity. This encounter showed newFNP that she does not know how to write a prescription for Flovent. She knows it's shameful but, amazingly, she never managed childhood asthma while in school. So tonight, she sits here with Nelson's Rediatrics open to page 768, reviewing asthma. Thankfully, she still has no furniture, TV, microwave, toaster, desk, etc - thanks to Atlas "moving" company - so she has nothing better to do. And, of course, newFNP takes her job seriously.

Also, the depressed patient. We've all had them. They want to talk. They have so much going on and newFNP does want to help them, but in the back of her mind during an encounter today, newFNP kept thinking that she had to get out of that room because there were tons of other patients waiting. It sucks. Every time you think you've managed to acknowledge their concerns, in Spanish, they have another. NewFNP is sorry, but she cannot do the counseling. None of the providers really can, yet the patients look to us for support. We are fortunate enough to have a social worker in our clinic, but that didn't get me out of the room in less than 45 minutes. Oops.

NewFNP saw a ton today. A fucking ton. And it was only in 9 patients. The M.D. in my clinic said to me as we were closing up shop, "This would have been a normal day for one provider." While newFNP knows that to be true, there is no way in fucking hell that she could have seen many more patients than she did today. And she feels so guilty whenever she have a question for the other providers. None guilty enough not to ask, but you know... newFNP still has so, so, so, so much to learn.

Cranial nerves and Depo

CC: numbness in legs and hands in 23-year old female

newFNP: hmm... neuro. Maybe neuromuscular.

PMH: Unremarkable. 2 kids. Using Depo for birth control.

S: Numbness in legs and hands x 2 weeks. Worse at night, with walking. Notices inflammation in hands with walking.

newFNP: OK, this is either MS, something rheumatoid, or it's a result of it being hot as shit outside. Better not chalk it up to "hot outside." BTW, newFNP was just thinking "neuro lesion" but a seasoned NP specifically said MS.

O: Let's see, nothing, nothing, nothing. Oh wait! Something. Ocular movement craziness. Reactive to light, no accomodation. Deviation to left with right-facing gaze. Neuro exam otherwise unremarkable but thank god because I couldn't deal with much more on a neuro exam on Day M.F.-ing 2!

newFNP: Can she understand my crappy Spanish? Is she fucking with me, thinking that I am a big idiot because my Spanish is less intelligible than her 18-month old's? Does she understand that I want her to follow my finger??? Consult!!

O: with one MD and one NP, both get the same results on the eye exam. Thank god because who wants to fuck that up on day 2?

A/P: 1) swelling as side effect of depo/heat - not my dx, but the MD told me that this is a common side effect.
2) neuro lesion vs. ophthalmological deficit - ophthalmology referral

Check back in December 2005-February 2006 to see when this woman gets her referral. That's the system when you have no health insurance. It blows.

Day 2

It was better today. Yesterday, newFNP was cursing her life choice. Today, she was feeling much better. Five patients yesterday, 10 patients today. Only 8 in Spanish. Still plenty of running around, not knowing what to do. Ah, the vertical learning curve... love it.

2 days at work, 2 days at the gym. NewFNP is a wonder FNP - taking care of others and taking care of herself.

It is so lame that it is 9:30 and she is getting ready for bed, but 6:00 AM is incredibly early so it's time to snooze.

NewFNP promises that she'll see something crazy and interesting soon and share it with you. Wait! She saw that today.

She'll remind herself... tell the story of the cranial nerve/Depo exam.

Paperwork

Lesson One:

Public programs require certain kinds of documentation that are not taught in school. They do not follow SOAP format. They defy logic. They are copious. They took up a lot of newFNP's time today.

NewFNP has to confess that she unloaded so many compaints to a fellow new FNP tonight that she have little left to share. A synopsis: 5 patients, all Spanish speaking and one requiring a corneal transplant as far as newFNP can tell. With 5 patients, who can really complain?

Oh wait, newFNP can. It's because it appears that in two weeks time, newFNP will be seeing around 20 patients a day. Hmm? Cuantos? Come again? That's right. Twenty. Other new NPs may have a more luxurious practice environment in which they see far fewer patients until they feel more comfortable. NewFNP appears to be learning in the "trial by fire" school of practice, whereas other new NPs are in a more nurturing, womb-like setting. It's hard to know which is better. Is it better to get your ass handed to you and land on your feet than it is to be eased into it? NewFNP doesn't know. She guesses that we will all learn, regardless of the practice philosophy.

An aside: to those interested in the national debate regarding universal coverage versus health savings accounts, there is an intersting article in the New Yorker this week. Malcolm Gladwell examines the concept of moral hazard and how it plays into the Bush plan for health care. He looks at its underlying theory and offers some arguments against it. It's worth checking out if you aren't super interested in getting an MPH but would like to have some insight into our national health care fiasco, er -- debate. http://www.newyorker.com/fact/content/articles/050829fa_fact

On tomorrow's agenda: pediatric well visits. Ah, the sweet, sweet world of squirming babies, defying newFNP's attempts to visualize their pearly TMs. She can't wait. They are sweet, those babies, but why do they hate to show their TMs?

Things newFNP learned today:
1) Seb derm - on an infant, you can use baby shampoo. Leave it on for a couple of minutes and then give it a massaging scrub that you would tip $10 for in a Soho salon. Tenacious seb derm in an infant? Give it a little 1% hydrocortisone for a week. Don't go crazy though! We all know the pitfalls of the topical steroid on fresh baby skin.
2) NewFNP hearts ePocrates. Shameless, she knows, and they don't even pay her. But bless them.
3) Bring snacks. That is no joke.

A Little Background

NewFNP is always one to underestimate herself, which is completely ridiculous, but nonetheless true. You all should know that going into our shared experience. NewFNP may tend to exaggerate how freaky it is to be brand new, but it's her hope that as her confidence grows, she'll be able to share the excitement and pride of growing and learning, and of providing a positive force in the lives of my clients.

A little about newFNP... she is a brand new Family Nurse Practitioner. She graduated in May 2005 from a prestigious and very old nursing school on the east coast, which shall remain nameless. Although newFNP may feel like an idiot right now, she was near the top of her class and fully intend to renew her Sigma Theta Tau membership once she A) gets a paycheck and B) pays off her credit card. Will they honor a student membership until 2010??? But I digress. NewFNP's program was an accelerated program. Most of the students with whom she attended school had non-nursing baccalaureate degrees. There seems to be some on-going debate about whether or not these type of NPs are "real" nurses, but newFNP doesn't really feel like going into all that now. Her undergrad major was "Community Studies." Ditto for not going into that now, but for all you other Slugs out there, rock on. NewFNP also has a master's degree in public health, which she loves. And which brings her to her current job.

She has accepted a position in a community health clinic in a major metropolitan area, serving a largely uninsured or under-insured population. She starts today.

Holy shit.