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.