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.