And the hits just keep on comin'

NewFNP has been on hiatus, largely although not entirely due to a lack of fun/interesting stories to share. Nonetheless, as newFNP indugles in a some moments of reflection here and there, she finds that there are some stories worth sharing.

In the on-going series of firsts, allow newFNP to share some of the new experiences she has had in the past two weeks:

-first patient passing out, becoming diaphoretic and having a BP of 68/42 and a HR of 40 during venipuncture.

-first patient with 8+ hours of uncontrolled epistaxis coupled with first experience of being unable to find 1:1000 epi and served with a side of being the only provider in the clinic.

-first realization that my 19-year old patient is engaged to and not the daughter of my 58-year old patient. Permit me an aside, s'il vous plait. Upon further questioning, this young woman disclosed that she and her partner had begun "dating" when she was an assumingly worldly 13-years old. Their son is three. What was her life like that a then 52-year old man was attractive to her? Where were her parents? Why did the man troll down that path of pedophilia? And why is the gentleman I know today, the same man who was screwing a child, so incredibly likeable?

-first suspected child abuse reporting call, only it wasn't suspected. Note: don't forget to ask what the child is hit with, ie. a belt, a hand, a shitty start to life.

-first time of blinking back tears due to feeling utterly overwhelmed, suprisingly not on the same day as the child abuse report.

-first time looking in an ear and seeing something resembling the aftermath of a roadside bomb. Shades of red and gray, jagged edges to a clearly blown TM. Tumor v. traumatic rupture of TM? Let's have the ED decide.

Oh, life. Is it too soon to ask for a raise?

Home sick

No, not 'homesick' as in newFNP is at work and missing her 1-bedroom apartment, but home sick as in see 'formula for success.' More time to devote to old NYT crosswords and The New Yorker.

But anyway, the time spent at home sick can't be all fun and games and cursing one's stabbing abdominal pains. As such, let newFNP tell you three little words that will make any newFNP truly embrace her 'sit-near-the-door' policy.

"I hear voices."

Super. I'm 30 minutes behind schedule and you hear voices. Are you sure you don't just have a cough?

Allow me to set the stage. My mid-40's patient was sitting on the exam table, paper gown and drape in place, and had an affect that quite frankly screamed medicated mental illness. She lacked emotion. She was treated with 2 anti-psychotics and 1 SSRI. Perhaps newFNP should let her psychiatrist know that something in her med cocktail wasn't fitting the bill.

So here newFNP is with the voice-hearing lady. After enquiring as to what the voices said to her and thinking, "please don't let it be 'kill the nice blue-eyed NP,'" I was relieved to hear the relatively benign, "Well, they are babies and they are telling me that I am their mother." OK, doesn't sound emergent.

Then she proceeded, as earnest as could be, "Is that normal?"

Hmmm... normal. Possible responses include:

a) "Normal, shnormal."
b) "I think the attraction to motherhood speaks to a lot of women very strongly."
c) "Who am I to say what normal is?"
d) "No. Shit no, that is not normal. Fuck!"

Now, if community-health-newFNP was an infertility-newFNP, she would lean more towards 'b'. But my community health clinic's scope of practice does not include infertility issues and this lady wasn't speaking about her deep-seeded inner desires for pregnancy. I chose a softer version of 'd' with a splash of 'b' thrown in for flavor.

This patient was not a sexually active lady, but believed wholeheartedly that there was a possibility that she was hearing these voices because she was, in fact, pregnant. Now that is getting into a whole area of religion and mental illness with which newFNP is not comfortable. Urine hcg negative. Let's get you in to your psychiatrist.

All in a day's work.

By the way, the swamp nurse article in this week's issue of The New Yorker made newFNP's job look like no work at all. NewFNP is all manicures and pilates compared to Miss Luwana. Here is a quote from the article:

"The mom I'm working with now is a sixteen-year-old unmedicated, bipolar rape victim and crack-addicted prostitute with a pattern of threatening to kill her social worker, who recently abandoned her baby at her ex-boyfriend's sister's, and who has an attempted murder charge in another situation..."

Now that makes me feel like I am working in a private practice.

The formula for success

Gentle reader, it is vomiting and diarrhea a-go-go here in newFNP land. We have seen countless children over the past few days with all manners of fluid evacuation. Patients have it. Staff members have it. Children of staff have it. Will anyone escape? My facialist is always telling me that I need a colonic in order to have perfect skin. Maybe she's got it all wrong. Maybe I just need some acute gastroenteritis to flush out the toxins!

Alas, the toxin-flushing argument is likely not going to be a winner with a worried parent. So what do you tell the patient's worried mom? Sure, fluids, fluids, fluids, but how much exactly? No worries, newFNP is here to provide the answer to that pressing question. As newFNP always says, there is no time like the present to review the exciting world of pediatric maintenance fluids.

Here's the formula:

First 10 kg: 100/ml/kg/day (aka 1000 ml if the kid is a full 10 kg - see how easy this is!)
Second 10 kg: 50/ml/kg/day
Each added kg: 20/ml/kg/day

For example, a 28-pound (13 kg) kid requires 1000ml + 150ml = 1150ml/day. Let's divide by 30 and tell the patient something they understand: No less than 38 ounces in 24 hours, buddy.

See, easy peasy! That is, if you have a calculator or are John Nash.

Oh, and newFNP is certain that everyone already knows to get a urine on these kids. A nice little quantitative measure of current hydration status. The whole "sunken orbits" is a little too subjective for newFNP. Maybe the kid was just not blessed with a doe-eyed countenance! Does that indictment really need to be a part of the permanent medical record?

Happy calculating!