Oink

Gone are newFNP's mojitos and walks along the malecon.  She is now back in the thick of it but very thrilled to have a new referral source to help out her patients.

NewFNP's clinic is very lucky to have our nutritionist, Red.  She is not to be confused with the pirate nutritionist, who must be swashbuckling with some bonny lasses as she has been nowhere to be seen.  No, Red has been a presence three days a week and thankfully so!

NewFNP had a sweet patient this week who wants to get pregnant.  Super!  Only it's not so super that she is over 350 pounds and has her periods 2-3 times per year.  NewFNP did some general education, gave her some folic acid and sent her to Red for a more thorough intervention.

Later, newFNP perused Red's note to see what, in fact, nutritionists talk about in their sessions, where they chart, etc.  What newFNP found was astonishing!

Those in the know are familiar with the SOAP note that providers use to describe the clinic visit: subjective history and complaint, objective findings, assessment and plan.  Learn it, live it, love it.  

Well, nutritionists apparently have their own format.  It goes a little something like this: problem, intervention, goal.  

PIG.  

The frigging nutritionists use PIG!  What the fuck?  That is so wrong.  So, so wrong.  Has no nutritionist ever stopped to think of the cruel irony?

PIG.  Seriously people, what the fuck.

Shit.

When newFNP last wrote, she noted that she had disclosed to a patient that she was HIV-positive.  NewFNP was wrong.  

She has AIDS.  

When newFNP told her patient that she was HIV-positive, her patient asked, "Does that mean I have AIDS?"  When she asked, newFNP knew that AIDS was a possibility.  NewFNP replied that she would know more when she got the rest of the blood-work back.

Her CD4 count came back today at 166 - an AIDS defining number according to the 1993 AIDS Surveillance Case Definition of the CDC.  NewFNP had a shit fit when she learned from the lab that the viral load was submitted incorrectly and could not be determined.  It matters and it doesn't.  The CD4 count is in the toilet, the patient is smoking crack and drinking on a daily basis and newFNP can't reach her.  She can't start on anti-retrovirals anyway - you don't want to have a patient fail her first, and best, option and - frankly - active debilitating addiction is not an ideal starting place for HAART if one is looking to prevent resistance.  

The situation is, pardon newFNP's French, fucked.

NewFNP wrote the prescription for Bactrim for PCP prophylaxis and attempted to reach her patient in order to get it started.  Of course, being precariously housed and without a phone, newFNP could only leave a non-specific message on her patient's friend's cell phone.

NewFNP's patient did not show up in clinic today to pick up the prescription.

NewFNP's passport is out and her dollars are exchanged as she is heading out for a longer long weekend in a far-away land.  But newFNP's patient will weigh heavily on her heart while she is away.

So, so sad.

End of the day blues

At the end of the day, newFNP likes the following types of patients: medication refills; normal lab results; well-child visits with vaccines already up to date; hell, even an uncomplicated UTI is fine!

But a blood pressure of 190/110 in room 4 and an as-of-yet undisclosed HIV-positive drug addict/alcoholic in room 5?  At 4:30?  Unacceptable.

Unacceptable and sad.

Again, newFNP will counsel that resisting the lure of daily crack and malt liquor use, coupled with exchanging sex for money and drugs, is a step in the right direction if one is interested in preserving one's health.  

But, even though newFNP's patient knew that she had engaged in some risky behaviors in the past, that did not make it any easier for her to hear the news.  This 6-foot tall, 130-pound woman who smelled strongly of booze sobbed, her face in her hands and her skinny body slumped on the uncomfortable plastic seat in the exam room.  

"Is that why I can't gain no weight?" she asked newFNP.  Could be.  But maybe the daily crack use has something to do with that as well.  Just a thought.

NewFNP frequently uses "we" when she is discussing sub-ideal behaviors with her patients, a la, "Sometimes when we are emotionally distressed, we gorge on mango Mochi" or "Sometimes we over-do it on shrimp dip during the holidays."  Nonetheless, when her patient asked why this was happening to her, newFNP was somewhat surprised to hear herself say, "Sometimes when we have a serious addiction, we trade sex for drugs or money and don't use condoms."  That elicited a nod of agreement from her patient and, truthfully, a little internal chuckle in newFNP.  Yeah, survival sex has played such a big role in newFNP's life.    

NewFNP did her patient's exam: lungs clear, heart regular, nodes everywhere, pap pending.  She drew lab work: CD4, viral load, RPR, heps AB&C, toxoplasmosis IgG, CMV IgG.  She gave her referrals to HIV clinics.  She encouraged her to attempt sobriety.  

It was a tough encounter for newFNP.  She wanted to handle this one right, to be a voice of support and caring in the life of a woman who has clearly lacked these two things in the past.  NewFNP thinks that she achieved that, but it is kind of hard to tell when your patient is drunk, probably has some underlying mental illness and is devastated.

Oh, and newFNP got the other patient's BP down to a marginal 146/95 and sent him on his way with three BP meds and a follow-up appointment.  It sucks to have to have given pretty decent care to one patient to the detriment of the other patient.  Both patients have potentially deadly conditions, both are rather poor at compliance, but only one got a full 45 minutes of newFNP's time.  

Take a tip

NewFNP is not going to sit here and tell you that she doesn't love herself a little Q-Tip action every once in a while.  It feels good.  And newFNP is not referring to an external cleaning, folks.  Au contraire, she is referring to the glorious sensation experienced with the insertion and rotation of the Q-Tip into the forbidden zone of the ear canal.

Mmmmmm......

But, people, please.  Once a week.  Twice if you are a true Q-Tip addict.  Do not push your billions of pounds of wet wax up against your TM.  

Because the amount of hard, brown wax - often replete with hair or other debris - which newFNP has been lavaging from canal after canal lately is getting overwhelming.  It is feasible, although as of yet unproven, that newFNP may have helped someone achieve a normal BMI through nothing more than a vigorous ear-cleaning.

When newFNP has a chief complaint of otalgia for three weeks, with or without decreased hearing, cerumenosis in atop her list of differentials.  And newFNP is a skilled clog-buster!  

When newFNP counsels patients to lay off the tips to prevent future cerumen log-jams, she frequently hears the lament that ears itch.  NewFNP knows that ears itch.  But guess what, dear patient?  Stripping them of every drop of wax will only worsen the pruritis!

When newFNP shares this fun fact with patients, she frequently receives a look that she has grown to know as the "you're fucking crazy and now I can believe nothing you say" facial expression.  She receives the same look when she says that, for optimal health, one need not eat red meat three times daily and again when she counsels that Gatorade is, in fact, not healthful when consumed in copious amounts.  

Water, friends, water.  Dilute it with hydrogen peroxide for the ears and straight from the tap/bottle/trickling mountain stream for the body.

Bonus info: In addition to being related to such conditions as polycystic kidney disease (gene PKD1) and tuberous sclerosis (gene TSC2), chromosome 16 is responsible for determining what type of cerumen you have - dry or wet.

D.A.R.E.

NewFNP has one word of advice for readers out there who may be considering dabbling in methamphetamine use: don't.

Please, just have some Two Buck Chuck or treat yourself right and share a $20 bottle of Pinot Noir with your special pal, but for the love of Pete, stay off the meth.

It's not like the skin-picking is bad enough.  Sure, it's awful to be paranoid and feel certain that there are bugs under your skin.  That's no good dirty poop!

But then you get the tooth rot, the horrible tooth rot and that is truly awful on several levels. 

For one, anyone who has ever heard of methamphetamine has probably heard of "meth mouth."  So not only do you have a frightful looking mouth, tons of people will know why your teeth are decayed brown stubs.

For two, it's hard to find a job if your mouth if full of rot, even if you have been clean for years.

For three, you feel self-conscious about your appearance and don't want to smile.

For four, you can't chew and, if you try, it hurts.  And you risk worsening infection.

And finally, when you are getting your dental clearance from newFNP, you can pull pieces of your rotting teeth out of your mouth for show and tell.  As if newFNP didn't believe that a mouth full of stubby brown and black nubs and one solitary whitish partial tooth warranted a hasty dental visit.

As newFNP has noted previously, her clinic sees more carbohydrate addiction that it does drug addiction.  Therefore, this man was her first patient with a mouth destroyed by meth use.  She understand that the rapid dental decline is attributed to xerostomia, a lack of oral hygiene and an increased consumption of excessively sweet foods, but is that it???  Is that all it took for her patient to go from normal dentition to horrible dentition in the course of two years?  And why did it happen after he had been clean for three years?  (Or is newFNP just naive and he isn't really clean?)

NewFNP is swirling her own saliva around in her mouth as she types.  After that frigging root canal and crown, newFNP has no interest in dental interventions in the future.

In fact, she just might go brush and floss right now!  

Vote!

For Hillary.

Super Tuesday Eve

NewFNP is so excited to vote tomorrow morning bright and early at 7 o'clock.  

She is relaxed due to an unusually slow clinic day today, she has a Super Tuesday outfit all picked out and she is so frigging excited to cast an historical vote tomorrow.

The debate last night just fueled her excitement although it wasn't really a debate, was it?  It seemed like Clinton and Obama have to find topics to debate about at they are so politically similar.

NewFNP is very much looking forward to January 2009.  Soon, the damage of the last seven-plus years can begin to be addressed and undone.  Please let's have some universal health coverage and please let's really leave no child behind and not just say we will.  Please let's preserve abortion rights and access to pregnancy prevention services.  Please let's not invade Iran and let's deal with Iraq and Afghanistan.  

Oh, how newFNP will wear her "I Voted" sticker with pride tomorrow!

Oh no you didn't!

Perhaps it is self-serving, but newFNP likes to stress the importance of self-management of chronic diseases.  It isn't only because newFNP grows weary of repeatedly sky-high blood glucose levels in clinic, but also because it really is the key to secondary prevention and because, come on, just come the fuck on and help a sister out in controlling your diabetes and high blood pressure.  

A simple easy step in becoming active in the management of one's chronic illness could be learning the names of the frigging medications you are taking on a daily basis.  Hell, don't learn them -- just write their names on the back of a McDonald's receipt and put the note in your wallet!  

NewFNP suggested this novel idea to a new walk-in, out of control diabetic woman yesterday.  She explained that this will help her providers in making medication errors, poly-pharmacy and all.  Her reaction?  

She started crying.  

Seriously?  That is what it takes to make you cry, dear lady?  NewFNP cannot imagine what her personal life must be like, but she assumes it is not fulfilling.  

NewFNP took extra time with this lady as the clinic was exceptionally slow and newFNP's keen powers of intuition told her that this woman was not the picture of togetherness.  She thoroughly explained the new meds she was starting, how to take them and what they were for.  Frankly, newFNP did a much better job in explaining the meds to her than she does with many other patients.  She repeated pertinent info.  She wrote extra info on the prescription bottles.  She wrote instructions on a separate piece of paper.

And guess what?  NewFNP's MA came to the office to tell her that the patient and her cousin wanted more information because newFNP "didn't tell them anything."  

NewFNP reeled around in her chair and incredulously asked the patient if she had, in fact, told her nothing.  While her 50-something year old patient looked sheepish, her cousin looked utterly entitled and demanded more information.  

NewFNP gave them the requested info -- again -- and sent them on their way.

Many patients tell newFNP that their former providers don't tell them anything.  NewFNP is sure that this is true on many cases, but a situation such as this really showcases how patients and providers might experience reality differently. 

Is it a victim-complex thing?  It must be easier to be a victim of one's disease and of an incompassionate health care system than to take what control one is capable of.  

Is it a shitty Spanish thing?  Did newFNP just waste twenty minutes with this lady, speaking incomprehensible Spanish?  While possible in conditions other than diabetes -- say, for instance, Loa loa filariasis -- this explanation is less plausible with DM2 as newFNP finds herself providing education on this topic with alarming frequency.

Maybe it is a life-is-overwhelming thing.  

Frankly, though, whatever the reason, it kind of pissed newFNP off.  

The Michael Jackson Parenting Award

NewFNP sees plenty of examples of parenting which she hopes to never incorporate into her repertoire.  

Most, but not all, involve feeding practices.  These include Gatorade or chocolate milk in a baby bottle when a child is 6 months old, Hot Cheetos in the hands of an 18-month old, fast food on a daily basis and tamarind/lead candies from the ice cream truck.

Some "don'ts" involve discipline and behavior modification.  Spanking and name calling. NewFNP will take a pass on these.  Threatening a child with vaccines if they don't behave.  Telling them that a shot won't hurt.  NewFNP frowns upon these as well.

Others involve soothing techniques.  Feeding a crying child just to stop them from crying is a no-no in newFNP's Theoretical Guide to Child-Rearing.  

NewFNP does, however, approve of gently rocking and employing a soothing voice to calm a child after vaccine administration.  However, when a mother soothes an infant by lovingly saying, "It's not my fault... they're assholes.  Yeah, there there, they're just assholes," newFNP believes that she must modify her approval of the soothing voice technique.  

NewFNP hears a fair amount of crazy shit, but she had never heard a parent attempt to calm a crying child by calling clinic staff assholes.   

A class act indeed.