Tuesday, May 13, 2008

Seriously... again?

NewFNP really wanted to do primary care.  She wanted to be out in the trenches, preventing diabetes and HIV and obesity and the like.

What a fucking sucker newFNP was.

In newFNP's clinic, there is a paucity of true primary care.  There are many reasons for this, not the least of which is that newFNP's patients come in the the clinic already sick.  NewFNP spends as much time putting out fires (read: lowering>500 blood glucose) than she does educating diabetics about the pitfalls of the all-carb breakfast.

But newFNP's clinic is also lacking in early intervention.  It's like the frigging uncontrolled disease rodeo and the providers need to lasso those buckaroos back into control.  It sucks.

Today's case in point.  Last week, a 31-year old man came in to see newFNP with what newFNP determined to be a diffuse cutaneous tinea infection - essentially covering his face - and a 23-pound unintentional weight loss over the previous five months.  Although he denied HIV risk behaviors, newFNP tested him.  

When his result came back positive, newFNP attempted to reach him by phone to get him back into the clinic.  It has been an ongoing struggle for our front desk staff to remember to ask for updated contact info and this was one patient whose new phone number slipped through the cracks.  NewFNP felt horrible in learning this.  How in the world would she contact him and get him into treatment?  How could she have let public health down and not updated his information herself?

Fuck that, newFNP decided.  She grabbed her clinic manager and walked the five blocks to his house today.  Pretty much every staff member that heard of her outreach plan looked at her as though she had utterly lost her mind.  One asked if she was bringing a gun with her.  She did not.  She knew that the address may not have been correct, but she needed to fill out the HIV case report and thought it best if it was completed to the best of her abilities.

Now, newFNP works in a metropolitan center that is rather renowned for its urban blight.  She is generally so busy that she doesn't leave the confines of the clinic during her work day.  But today she ventured out and really saw what all the fuss is about.  Sure, drive by shootings and gang warfare get all the press.  But what the fuss is about is a lot of loafing and mid-day drinking.  Perhaps, on a larger scale, one might say that this fuss is about unemployment and bleak future prospects, but newFNP has been so damned heavy lately - she just can't go into all that.  She, thankfully, was spared the gang-related drive-by shootings.

As she walked those five blocks, newFNP was struck by how an eleven mile drive really transports newFNP into a whole different world.  When newFNP hits up the liquor (OK, wine) store, she rarely - if ever - sees groups of people hanging out or talking on pay phones, all the while with their toddlers in strollers drinking extra large juices or their school-aged children decidedly not in school.  When she has a weekday off and walks to the store, it's rare that she sees groups of middle aged guys just lounging on the front lawn, shooting the shit and drinking Budweiser tall boys.

But that is exactly what she saw as she walked up the street, clinic manager in tow, and cautiously approached the address listed on his chart.  NewFNP's clinic manager inquired as to the patient's whereabouts, to which one man replied, "You mean the guy from Honduras?"  Hmmm... that is not information with which newFNP was armed.  Another guy said, "Oh, you mean the one with the spots on his face?"  Bingo.

According to the Budweiser posse, he did not in fact live at the house, but across the street. One gentleman offered that newFNP's patient was cooking in the back and went off to retrieve him. The men told newFNP that there was a point during which her patient could hardly get out of bed and they wondered what was wrong with him.

It's safe to say that her patient was surprised to see her.  She asked him to come with her the clinic and he agreed to be there a couple of hours later.  When he arrived, this 31-year old man's temperature was 103.1.  His lungs were junky - wheezing and rales.  His O2 sat was 96%.  

Not only did this guy learn of his HIV+ status today, he was transferred by ambulance to the hospital to rule out pneumocystis carinii pneumonia, an AIDS defining diagnosis.  

It was a heartbreaking appointment.  He lives alone.  His entire family is in Honduras.  He has no phone.  He has been clean and sober for a mere six weeks.  He told newFNP that it would have been better had he never known, that he would be better off dying.  

NewFNP told him about the advances in care and medications, about the many services available to HIV-positive people in this huge city, about how he has the resources, albeit limited, of newFNP's clinic to support him.  But newFNP knows that this is a socially isolated, marginally literate, extremely poor man whose social circles may be more likely to shun him than to support him.  Honestly, newFNP is as concerned with his emotional well-being as she is with his physical.

And, for the second time, newFNP gave an HIV+ test result not when the patient was generally well and had natural defenses intact, but when the patient was ill.  When they likely had AIDS at the time of their diagnosis.

That is not right.  It's not right.


Anonymous said...

Damn dudette...

I could tell you some fluffy b.s. about how I'm glad you had the gonads to track the guy down and you were the one that was "meant" to take care of him.

But the whole situation just sucks hardcore.
So sorry.

Anonymous said...

It's so sad that people still get death-bed HIV diagnoses. I work in an area with an epidemic infection rate for our state. We're trying to integrate routine HIV testing for all our patients, but it's still a new concept for people. And it's especially hard to catch that HIV early when people don't come to the clinic until something is terribly wrong.

Dave said...

Hi new FNP:
As an old PA and one who has done more communication to NPs and PAs than anyone else, I applaud your blog.
Email me off line please.