Wednesday, April 25, 2007

Va-va-va.... hey, wait a minute

As of late, newFNP has been using her spare time in between patients to help the higher-ups at work compile data for a new program application. As such, she has learned many statistics about the area in which she works. For instance, she works in the area that has the highest all-cause mortality in her county of residence. The area has the highest rates of uninsured adults and children in the county. The majority of the residents in her clinic service area speak a language other than English at home. Only a quarter of the residents have graduated from high school. The average income is in the low 20,000's.

All this to say that the patients who newFNP serves are poor and largely disenfranchised. No shit, right? They're waiting 2 hours for a 15-minute appointment at a free clinic after all.

Generally, when newFNP is conducting a health history during a physical, the past surgical history that she elicits include cholecystectomies, BTL's, hysterectomies and traumatic injury repairs. It is rare, exceedingly rare, that newFNP has a patient who has had breast implants, a tummy tuck and a face lift - all conducted in the US. Any plastic surgeries that newFNP's patients may have had are generally conducted in Mexico.

So let's see... breast augmentation. What does that even run a person? Thankfully, newFNP will never have to know! But she thinks that it is in the neighborhood of $5000. Tummy tucks? $7000? Who the fuck knows? And a face lift? What, another $5000?

So if you are dishing out upwards of fifteen grand to spruce up the bod, it seems egregious to then seek out the services of a free clinic and use public funds for your physical. At the very least, it seems as though a generous donation is in order.

NewFNP didn't say anything, though. She just did her first implant breast exam and then sent out the referral for the mammography.

Monday, April 23, 2007

Breaking the law

It was yet another busy Monday in newFNP's clinic and, with newFNP still fighting her URI, she was fighting to stay afloat. She has eight charts at home to finish and some unfinished business to attend to tomorrow.

As such, newFNP was certainly not counting on a knock on her exam room door at 4:15 as she was conducting two well-child checks on siblings. She never expected her colleague FNP to say, "You have got to see this. Someone forged a prescription on a patient you saw last week."

But this is, in fact, exactly what happened.

Apparently, the two-year old patient's mom felt that the Ibuprofen prescribed by newFNP just wasn't enough. She thought that she should just add on "amoxicillina 250mg." Just like that. Just a Spanish language medication and dosage written in chicken scratch above newFNP's graceful and fluid script.

Thankfully, the pharmacy faxed over the prescription in order to verify it. They, however, asked newFNP to verify the sig, not to verify that it was a big fat forgery. What the fuck? Doesn't the pharmacist say something to the patient? Something such as, "Ahem, do you know that it is fucking illegal to forge prescriptions, you cow!?! You know, illegal as in jail."

The patient's mom had the audacity to call the clinic today, demanding that her child be given Amox and threatening to take him to the hospital, change clinics and make a scene if we didn't give it to her. She insisted that newFNP wrote her the prescription. NewFNP refused to talk to her. She let her clinic manager know what the situation was and went about her business.

Why do patients like this always think that threatening to change clinics is something newFNP will respond to? Please, newFNP will pay this patient five bucks to change clinics so she never has to deal with her fraudulent-prescription-writing ass again.

So long sucker!

Sunday, April 22, 2007

Ahhh... cable TV

NewFNP likes to fancy herself as healthy, but here she is - sick again. NewFNP attributes her illness to being exposed to all manners of rhinoviruses day in and day out and believes wholeheartedly that it is only the most virulent of said viruses that tend to knock newFNP on her ass. Which is where she has been all weekend. On the couch, flat on her ass, in and out of consciousness, thanking God that her boyfriend had the good sense to buy a huge flatscreen TV so that she may be entertained by the likes of Dirty Dancing, CSI and Caddyshack.

Nobody puts Baby in a corner.

NewFNP did take some time during her convalescence to think about her current employment situation. She reviewed some physical assessment texts and thought about where she might be taking her career. As we all know, her attitude is in the toilet. However, newFNP would like to change that and certainly does not want her career to follow that path.

But here is why newFNP's attitude sucks.

Sometimes people just break newFNP's heart. When newFNP hears about food insecurity from a featherweight 22-year old man, it just makes her emotional. Imagine leaving one's country to come to the US, in hopes of a better existence, and not being able to find adequate food. Of knowing that you have latent TB, but not being able to afford the $10 medicine to avoid active TB infection. Of finally securing a job, but working six days per week and not being allowed to leave early to get to the clinic. There was something more about this patient, though. His modesty, his sincerity... he really touched newFNP.

Then there are the people who make newFNP want to scream. This week, a patient told newFNP that no matter how much he weighs, he never changes in size. In fact, he claimed, one time he lost one hundred pounds, but still wore the same sized jeans. "One hundred pounds?", newFNP verified. Confirmed. One hundred pounds and still a size 42 waist. Diagnosis: delusional liar? Reality challenged? How is newFNP supposed to help someone who has clearly lost touch with all that is real? NewFNP notices that her trousers are roomier of she loses 1/100th of a pound.

And finally there is that old chestnut about support staff not providing support. NewFNP does not want to micromanage, nor does she have the time to do so. But when newFNP's reputation is on the line, you bet that she will be all over the staff's asses in order to get things done. You betcha that newFNP can find 30 seconds in between patients to ask if phone calls have been made and abnormal pap logs have been updated.

A friend of newFNP's recently noted that he felt that newFNP sometimes feels anger toward her patients. NewFNP disagrees, but she certainly does feel frustration toward many patients. Quite simply, how could one not feel frustrated given the challenges one faces in community health and probably in all healthcare settings?

Working through these frustrations is one of the challenges that newFNP faces. Sometimes she is great at it, sometimes not so much.

Tuesday, April 17, 2007


NewFNP works in the poorest service area within her county. Almost every single health outcome indicator (overall mortality, teen births, infant mortality, obesity, cardiovascular mortality, insurance coverage - you get the picture) is the worst in her entire huge county. Her patients are exclusively covered by public health insurance, if at all.

So when newFNP has a patient who has some wealth accumulated, she finds it, frankly, a little surprising.

For instance, when newFNP asks her patient if she has health insurance and her patient responds that, no, she doesn't qualify for health insurance because she owns her home, newFNP is surprised. NewFNP's patient's net worth is greater than that of newFNP, yet newFNP is working, paying off five years of grad school loans and going home to her rented apartment, albeit a sweet-ass apartment with hardwood, washer & dryer and arched doorways located in a chic and safe area of her city. Perhaps newFNP will one day achieve the dream of home ownership herself, but she is currently unwilling to sacrifice her HMO and 401(k).

NewFNP's landed gentry patient must think that state-funded insurance is the creme de la creme, because she asked newFNP if newFNP "qualified" to receive it. Almost! If the state took newFNP's loans into account, she just might qualify for public insurance and section 8 housing!

At any rate, newFNP believes that this speaks to the need for universal health insurance. Should newFNP's patient have to sell her house in order to qualify for public health coverage? Does being a homeowner make newFNP's patient a woman of means? Might newFNP's patient end up costing the public health system more money if she can't get the care she requires? No, no, yes.

NewFNP does not like to think about how much longer we have until the next presidential election, but is she ever hopeful that the pendulum will be swinging left!

Friday, April 13, 2007

A community health fairy tale

NewFNP works for an organization that has four clinics. She is generally at one site, but floats from other sites time to time. Some might say that we are all sister clinics. Others might call one clinic or another an evil step-sister.

As newFNP's readers know, newFNP's clinic is down one full-time provider. The other NP works three days per week. That leaves newFNP alone two days per week. So fine, newFNP has to go it on her own. NewFNP has to fill out the paperwork for all of the kids needing school physical documentation, organize the type 2 diabetes group, help the HR director re-apply for the HPSA score and write letters for patients applying for disability. By the way, is having dyslipidemia a disability? Hmmm, newFNP thinks not. Denied!

Did newFNP mention that she has zero hours of administrative time during her work day?

All this to say that, frankly, newFNP doesn't need anything extra. NewFNP most definitively does not need another clinic, her organization's biggest clinic, sending her a walk-in s/p abscess I&D wound care patient. And furthermore, newFNP does not need that patient to walk-in without a either a courtesy phone call from the dickhead at the front desk of the other clinic or a copy of the patient's registration info and progress note faxed from the clinic.

Why can't other people understand that taking five minutes to extend professional courtesy makes a difference? This is what continually floors newFNP about working in community health. Some of her colleagues just don't have common sense, nor do they think to extend courtesy to each other. Certainly a phone call is a chance to express thanks for the extra work, to give a heads up that you might be keeping your staff over an hour late due to the complexity of the walk-in patient and that you will likely be missing a date with your boyfriend.

But no. In walked newFNP's patient with a 2-inch gaping wound in her buttocks, covered with approximately 800 bandages and 35 rolls of tape. It took 15 minutes just to get the bad dressing off this poor lady's irritated skin. After diluting the wound with one liter of diluted hydrogen peroxide, newFNP packed her patient's lovely lady lump with three feet of iodoform. Three feet. During this process, newFNP's patient told her that the other clinic sent her because newFNP's clinic was bigger, that the evil step-sister clinic was closing early and that they didn't have the supplies to do the dressing change.

Interesting phenomenon indeed. The clinic had the supplies to slice open this woman's butt, pack the wound and cover it, but not to check on her healing and change her bandage.

It's one thing to have patients dumped from other clinics, but to get screwed by one's own colleagues! That just leaves a bitter taste in newFNP's already tart mouth.

Tuesday, April 10, 2007

Bathtub safety

NewFNP has a hunch that it is going to be a grand day at work when, driving to work at 8AM, she sees no less than five commercial sex workers standing on consecutive corners, white patent faux leather thigh-high boots, Daisy Dukes and Huggy Bear caps-a-plenty. Is there no vice squad in newFNP's major metropolitan area? Can the lady walking down the street in a tee-shirt and no pants or underwear find it within herself to cover her huge ass? What the fuck?

Seriously people. Can't we all agree that there are certain things that newFNP, as well as the majority of the rest of the world, do not need to see except at the movie theater or on C*O*P*S? There is only so much vice that newFNP can tolerate so early in the morning. This morning exceeded newFNP's quota.

So, hours passed with no obvious prostitution, leading newFNP to think that her day was normailzing, when newFNP was saw the chief complaint of "hurt her vagina." Now, newFNP is no stranger to curiously worded CC's, such as "little ball on the peanuts, " "soap in the right eye x 9 days" and "cough and flames x 2 days." What does newFNP have, a dragon for a patient? So, clearly, "hurt her vagina" isn't the oddest CC, but it's no "med refill" either.

Apparently, newFNP's 200-pound patient had slipped while exiting the tub. Her fall was broken by the tub wall, with her labia bearing the brunt of the force. Her left labia majora to be exact.

NewFNP uttered the words "oh shit" upon seeing her patient's horribly swollen purple labia. It was the size of newFNP's fist. It looked like a seashell. NewFNP imagines that she felt what all men feel when they see another man take a hit to the testes. Youch! Again, newFNP did screen for abuse - none. All of the pelvic bony structures were intact and the patient had full ROM at the hip, thus no x-ray for this uninsured patient.

Ice. Ice. Ice. Ice. Ice. Frozen peas baby. Mold 'em to your downstairs. Motrin 800mg TID with food. NewFNP thinks that pelvic rest is an obvious plan, but said it nonetheless. A little prayer that this will resolve quickly for the patient.

Man, oh man. What a day.

Tuesday, April 03, 2007

NewFNP's patients need the ERA!

Gender equality has yet to make it to newFNP's patients. Sure, in our practice, the medical and dental directors are both women, as are the CFO and COO. The majority of the providers are female. NewFNP can't imagine that any of them go home to loser husbands who sit on the couch, drink beer and watch TV.

Yet newFNP has patient after patient tell me that they can't find a moment for themselves, that they care for children and homes all day long, only to care for children, homes and partners once the men come home from work. And these women have complaints of fatigue, dizziness, "low blood pressure," and sadness.

And they have no friends. NewFNP asks about friends/support systems, but these women don't have them. NewFNP screens every patient for IPV, but the majority of these women deny abuse. They are just socially isolated. If newFNP didn't have her girlfriends, oh man, that would be a grim existence indeed.

Now don't everyone go and write newFNP, telling her that she is naive and all of these women are abused and denying IPV. Please. NewFNP doesn't screen just once and she gets that it takes more than once to gain confidence. Some of these women will disclose abuse; others are just married to beer-stained couch cushions.

NewFNP knows that we are supposed to be culturally sensitive, but newFNP finds it pretty fucking difficult to be sensitive to husbands/fathers who are as lazy as tree sloths. Yeah, yeah, these guys work all day, but so do their wives. Caring for children all day long is exhausting. How much pretend play can one engage in? NewFNP isn't talking about in the bedroom now, but speaking of... Is it any surprise that these women have no sexual desire? NewFNP thinks not. In fact, newFNP is hard pressed to think of a woman who is going to want some sweet lovin' if all she does is work around the house and see her husband watch WWF while sipping on a cool Pabst Blue Ribbon.

NewFNP had an awesome 28-year old patient today who is a mother of four. She does aerobics most days making her a clear outlier in newFNP's practice. Her husband would like another baby, mostly, she believes, to keep her around the house more. She told him that is would be a cold day in hell before that happened. NewFNP felt so proud of her!

Now newFNP is all riled up and needs to see if her boyfriend did the dishes or made the bed or did something today!