Tuesday, March 18, 2008


It would have been easy for newFNP to just blow off the attitude of the almost thirteen-year old obese boy who begrudgingly attended his well child visit with his mom today.  Eyes steadfastly examining a single spot in the floor, his 213-pound frame turned away from his mom and from newFNP, he initially refused to respond to newFNP's questions or to his mom's exasperated pleas for the responses.

"You see, Doctora?" she lamented.  "This is how he always is."

NewFNP cares for this boy, his two younger brothers, his mom - who has diabetes - and his grandma who also has diabetes and who has had two strokes.  His mom cares for herself, her mother and her four children as best she can.  One older boy is on house arrest.  As newFNP flipped back to the last physical, she saw in her handwriting: father incarcerated.

NewFNP knew that this attitude was about that.  She asked the patient if his dad was still in jail - he is.  She asked him if that was why he was upset.  It was.  She asked the patient's mom to leave them alone, not quite certain how to broach the subject of the kid's attitude and his father's incarceration.  These topics are difficult for newFNP - she often feel like the emotional equivalent of a bull in a china shop when she has to discuss them.

True to that expectation, newFNP's start was rocky.  She asked her patient, whose emotional pain was weighing heavily in the room, to please look at her.  He refused.  She told him that it would mean a lot to her if he could just look at her.  He made a micro-movement toward her, decided against it and again faced the floor and told her no.  

NewFNP said, and in writing this she knows that it is harsh, "OK, so you just want to sit here and be a jerk?"  He said yes.  This affirmation opened the door for newFNP to ask him who has told him that he is a jerk.  

And the floodgates opened.  NewFNP is not sure what she would have done if they had not but it doesn't take a psychic to know that this kid has had a lot of negativity directed towards him.  'Jerk' may have been tame compared to other names he has been called. 

NewFNP spent the next twenty minutes listening to this devastated kid cry about how he misses his dad.  It was absolutely heartbreaking.  He doesn't want to go to school because his dad used to take him.  He doesn't want to go to the park because he sees all the other kids with their dads.  When someone picks on him at home, no one is there to defend him like his dad used to.  He is about to turn thirteen and all he wants for his birthday is to visit his father in prison.  He is concerned that he will be deported and that he won't see him again.  His uncle is mean to him, tells him bad words and to "calm the fuck down."  His aunt yells at him.  His mom is frustrated with him.

NewFNP was, frankly, not sure what to do.  Obviously, this kid is at high risk for school failure, perhaps for criminal behavior given that his brother and father both modeled it for him.  NewFNP knows that he is also at high risk for diabetes, that he already has fatty liver infiltration and she assumes that part of this overeating has an emotional component.  She made an executive decision to blow off the medical concerns for today - at least in part - and to focus more on his emotional decompensation.

She told him that he has already seen too much and suffered too much for his young life, acknowledged that life has dealt him an unfair hand, allowed him to grieve his loss and his loneliness.  She talked to him about his potential, about making good decisions and about how he is loved.  She told him that she saw a sweet person inside who wanted love and caretaking.  

She just let him cry and tell his story as, in the world according to newFNP, telling one's story is an important therapeutic process.  

At the end of the visit, newFNP listened to the kid's heart.  She let him listen to it - it was the first time he smiled during the visit.  She asked his permission to check his blood and ordered a cholesterol, a comprehensive metabolic panel and an A1c - just in case.  She told him that she would see him in two weeks.  The nutritionist referral will have to wait until then.

NewFNP left him in the room and spent a few minutes with his mom.  She asked her to tell him every day that she loved him.  She asked him to tell her bullying brother to lay the fuck off.  She told his mom that she was very worried about this sensitive and hurting boy.

NewFNP was e-mailing a pal from public health school to ask about mentoring programs for this kid when she heard him call her name.  She turned around and he gave her a big hug and thanked her.  

Even though newFNP thought how she was utterly powerless to change this kid's life during her encounter with him today, she simultaneously felt so grateful for the opportunity to say kind words to a troubled adolescent.  She needed that.  Clinic has been so overwhelmingly thankless lately that she had been questioning whether or not she could stay.  

Even though newFNP didn't do much medicine with this guy, she definitely did some nursing.  And some social work.  And it felt really, really good.


Anonymous said...

You go, NewFNP. Awesome job. You probably helped this poor kid more than you even realize. Hopefully his mother will step up and heed your advice.

swedishnurse said...

I've been reading your blog for about a month or two now. I'm a new FNP too. I've forwarded your blog to a number of my other FNP friends. You are a great writer and your stories are always interesting. When I read this story today I seriously almost cried. People always ask me if I want to go to medical school eventually or if I just want to "settle" for being nurse. This story exemplifies how I see nursing as being completely different from medicine and why I would choose nursing over and over again. Keep up the good work!

npsusan said...

great job, newFNP! One kid like that, when you can really touch them.....can carry you for a long time!

Serena said...

Yay yay yay!!! I'm so impressed and glad you were able to take the time to spend a little of your day with this guy. It really does matter for a kid to have an adult who listens to them!!! It's such a trip how often your posts sound like my experience. I'm glad to know that there was some brightness for you in this, too.

Teeny Jo said...

This is why I decided to become a nurse. THANK YOU for this post!

Anonymous said...

from a new fnp outside of santa cruz: thanks for posting this....community health can be so DIFFICULT sometimes, and it just drains you by the end of each shift. Sometimes, like in this situation, just listening and not so much "doing" is the real answer for what the patient actually needs. You might never know just how important this visit was for the poor kid. Kudos to you....and a big pat on the back.

Anonymous said...

I'm in my last clinical of my last year of NP school. I LOVE that I have the extra time to really listen and be a great NURSE to my patients at my community health clinic in Cambridge, MA. I'm terrified of losing that once I get into the workforce where productivity is pushed... 15 minute visits are standard... Ugh.

Leslie said...

You rock, NewFNP! I discovered your blog through a friend in my NP program and have been reading all of your entries for the past few days instead of studying. I am just starting the advanced practice portion of my NP program and find your stories hilarious and heartwarming. This one in particular really jumped out at me. What a wonderful encounter, and you handled it beautifully. It sounds like you really made a difference in this kid's day, and possible in his life. You sound like a wonderful practitioner!