Massive

NewFNP's patients are coming in sicker. Totally anecdotal, of course, but what on newFNP isn't? She doesn't have anyone who has scratched a hole in her skull and exposed her brain, as Atul Gawande writes about in this week's New Yorker, but she has just had people come in that, truthfully, should be seen by internal medicine or psychiatry or, in this case, oncology, surgery and radiology.

This young, single mother of three first noticed the small bump on her upper arm, beneath the surface of the skin, about a year ago. The demands of single parenthood and her low-paying/no-insurance-providing job had kept her out of medical care. When asked to describe the size of the initially noticed lesion, she drew a circle 4mm in diameter.  When newFNP measured the mass in clinic, it was 12.5 cm by 15 cm.

It was firm.  Not firm firm, but softly firm and disturbingly firm.  Soft tissue sarcoma firm.  Oh shit firm.

NewFNP saw and felt the mass and instantly flashed back to her recent patient with two huge malignant masses.  She wrote the urgent referrals to her county system, but she knows that this young woman will need to go through the emergency department in order to get the CT and biopsy that she needs.

NewFNP is sick of this.  She is deeply frustrated by having nowhere to turn for her patients who need more care than newFNP's clinic provides.  She is frustrated that her major metropolitan area's community clinic association has so few resources for the community clinics.   And she is frustrated that she is so busy on a day to day basis that she cannot create her own backroads system of referrals.

Our patients wait.  They wait until their symptoms are unbearable.  They wait until they borrow someone's glucose monitor and see "HI" and then they wait some more before they come in, wondering if their 30-pound weight loss and dry mouth and frequent trips to the john could be caused by diabetes.  They wait until their likely rhabdomyosarcoma is visible from across the room.

In writing this, newFNP realizes that this is only half true.  There are the other group of patients who present for every URI, hangnail, bruise and stomach ache that they experience.  NewFNP sort of wishes that these worried well would come in less and the very needy new diabetics and cancer patients and HIV/AIDS patients would come in sooner -- when newFNP and her colleagues could actually help them.

Small world (after all)

As you may recall, newFNP was feeling fed the fuck up with her clinic.  This prompted her to send her CV to her local major university/research center/medical center.  This was on Saturday at 5PM.  She was expecting that they would call, but that they would call in a month. 

They called Monday afternoon.  And not just HR -- the medical director of the position for which newFNP applied.  She was seeing patients and was too astonished to answer the phone.

She was recounting her tales of woe and her desperation and job-seeking and rapid return phone calling to her pal and Scrabulous nemesis during the walk to the Death Cab concert Monday night.  "Hmmm," he said, "That sounds like the project that CHO works on."  Confirmed.  An MPH colleague, to whom newFNP was a mentor during MPH orientation, has worked there for years.  

Last night, newFNP was dining with her other public health gal-pals in honor of a great public health pal visiting from her South African international health job and was detailing yet again her frustration with work and her possible venture into academic medicine.  

"Come to South Africa!" newFNP's friend stated.  Interesting, but pass.  Amongst other things, if newFNP ever wants to get married, it seems as though a move to South Africa might decrease those odds.

As she described the research area, another friend stated, "My brother is doing that same kind of research."  

"What's his name?" newFNP asked.  Medical Director.  NewFNP had spent a half an hour locked in an exam room, talking to him on the phone just hours before.   

Has newFNP recently mentioned that she lives in a really major, major metropolitan area?  This project has a staff of ten.  Ten.  NewFNP isn't mystical or religious or a believer in fate, but these coincidences are somewhat testing her beliefs (or lack thereof).  

And she met with the medical director today.  He didn't promise newFNP anything, but he did say the magical words, "Well, you are very well qualified."  

Word.  NewFNP has mad qualifications.

If you can't take the heat...

NewFNP is hot.  She is - sadly - not 'hot' in the new hair-do, flattering trousers, sassy flats sense of the word.  No, she is talking about the Holy shit! Who turned up the heat and why in the hell don't I have central AC kind of hot.

And newFNP is also frustrated.  This is not a good combination.

NewFNP is sending out a cry for help.  NewFNP does not like herself much of the time anymore when she is at work.  She is mean.  She hears the harsh tone of her voice and cringes.  She is endlessly frustrated by the half-assed work of the support staff.  Each and every day, she is correcting other people's mistakes and dealing with other staff members' shitty attitudes and disappointed by the lack of improvements in the system despite her efforts.  She hears that people have called her bossy, which is true, and a bitch, which has been true but is not something newFNP is in her outside clinic life.  NewFNP wants to not care about what people think, but she does.  And newFNP does not want to be a bitch.

NewFNP spends so much time looking for unfiled labs, asking her MA to find unfiled labs and doing laps around the poorly designed clinic in an attempt to find her MA in order to ask her to find unfiled labs that she could probably see an extra 1-2 patients per day if this one issue were to be solved.  She is fed up with the growing piles and piles of unfiled charts on the floor of the file room while the clinic staff sits and chats about whatever crap it is that they talk about.  She is frustrated that the very young and very overwhelmed clinic manager is impotent when it comes to actually managing the clinic and the staff.

As an aside, there are many reasons that drive the resistance against change in newFNP's clinic.  When newFNP eventually leaves, she'll share them with you and it will make your heads roll.  But the infrastructure is so unique that it would be a dead give-away if anyone in the know was to stumble upon the blog.

So what to do, what to do?  NewFNP doesn't want to leave, but she doesn't want to be a bitch and she doesn't want to be frustrated.  

Her CV looks pretty slick.  Will her local major university -- and her alma mater -- think so too?  Because newFNP submitted it in an act of sheer desperation.  She is looking for options.  And a pension.  And a salary increase.  But to leave would mean giving up what brings newFNP joy - caring for her patients.  

A conundrum indeed.

Thankfully, newFNP has the Death Cab concert, her super-duper friend from South Africa visiting and not one but two grad school pals visiting this week.  She'll be too busy with her real life to worry about her work life.

Atypical.... and typical

On the day of the first power outage at newFNP's clinic, there was a teenage boy waiting to be seen who had - the day before - fallen down a flight of stairs, broken his nose, split open his lip and fad a face that resembled Chunk from 'The Goonies'.  He had been seen in the ER and just needed a referral to get his face fixed.

NewFNP talked to him and his parents outside, grabbed a flashlight with the brightness of a penlight, went inside the cave-light clinic and finished the kid's referral.  This was month's ago, was no big deal and, frankly, newFNP had forgotten all about it.  

Apparently, the CEO had not.

During the clinic's staff meeting, he acknowledged newFNP's contributions in front of the entire staff.  NewFNP can imagine how he told the story of her relatively minor contribution to patient care and then called out her name several times, only to have someone say the inevitable: She's still seeing patients.

NewFNP's one moment to shine and she missed it!

Oxy

In case anyone missed the memo, community health is challenging.  It's not only that patients are ill and uninsured and have more medical and emotional needs that the clinic and any given provider can reasonably handle.  

It's also that the patients just don't 'get' the system.  

For instance, newFNP had a charming but terminally ill seventy-five year old woman walk into clinic today.  The woman has cancer.  How does newFNP know this?  Well, it helps to have pathology reports noting lung cancer and metastatic adenocarcinoma.  However, even without the reports, newFNP wouldn't have missed this one.  

She wasn't on oxygen, she didn't have a tracheostomy.  So how could newFNP have known that she had cancer?  Did she call Miss Cleo's psychic hotline?  Does she have x-ray vision?

Nope, it's because the woman had two huge visible tumors.  One was on her anterior chest wall, about the size of a baseball and just as hard.  The other was on her abdominal wall.  It was rock hard as well... and draining.  And it was large.  Really large.  Hugely crazy large.  Bigger than Posh Spice's fake boobs.  NewFNP is talking 8-by-6 inches large.

Now, this woman has known since January that she has inoperable cancer.  And where might her oncologist be?  In a state some twenty-five hundred miles away from newFNP's clinic.  She stated that she got bored and just wanted to get away.  NewFNP appreciates that, if one is dying, they should do whatever the hell they please.  Travel the country, visit the ghetto!  

But just one thing - get your oxycodone refilled before you leave.  

As newFNP has previously noted, the walk-in scheduled med refill is not one of her favorite visits.  But when you have very obvious cancer, newFNP doesn't even think twice about writing that oxy prescription.  Knowing what lay ahead for this woman, newFNP accompanied the prescription with a referral to the palliative care team at our local public hospital.  

Skills Lab

This is what passes for a rich Monday evening in newFNP's life - the new Death Cab for Cutie album on heavy rotation, an 80-cent pig's foot from the El Salvadorean market and some borrowed instruments/pilfered sutures from clinic.  

Good times.  

 

Hold on

Clinic is a roller coaster.

In one room, you have a scrawny four-year old in full Spiderman regalia flexing his little biceps telling you to look at his muscles while awaiting you in another room is a social worker from children's services telling you that she needs to remove two children who are currently in the clinic from their father's custody and she wants your help.

NewFNP chooses the first room. She'll take a pass on the second. Alas, the second room chose her as well.

NewFNP has sympathy for people who have addiction problems. But it is hard to have sympathy for parents who cannot get it together to find help for sobriety while they are pregnant. When your newborn screens positive for cocaine, that is - frankly - bad. It's just bad. There is just nothing good about the fetus-cocaine combination. NewFNP received a phone call from the hospital letting her know that she would be seeing this baby for her newborn exam and that the children - the newborn and her 18-month old sister who shares a name with a slang term for marijuana - were in the custody of their father under the supervision of the department of children's services.

She was unprepared for the social worker to appear in clinic, to tell her that the dad's tox screen was positive for marijuana, and to tell her that she would be taking the children into protective custody after newFNP did her newborn exam. And, oh, by the way, would newFNP help her?

This is where newFNP is a huge spineless jellyfish. She has this frigging affliction of wanting to make life easier for others, all too frequently sacrificing her needs in the process. What she should have said is, "No way. NewFNP will do the exam, but you call the police and you do not put newFNP in the position of betraying her patient." But the social worker had already stated that she didn't want to call the police and escalate the situation, a point of view to which newFNP is not entirely unsympathetic.

So newFNP did the exam and - it pains newFNP to say - lied to the father and told him that she needed to re-weigh the six-pound baby to ensure accuracy. She exited the room, baby in hand, and deposited the newborn in the hands of social worker #2. She returned to the room, laden with guilt, with the social worker and the clinic manager. The social worker explained to the father why the children were entering temporary protective custody. As the shock wore off and the reality set it, this young man - covered in gang tattoos - wept. He cried. He hit the wall. He lifted his shirt to dry his eyes, revealing even more gang tattoos.

NewFNP knew that she was betraying the implicit trust of the provider-patient relationship the entire time she was participating in this shady operation and she felt appropriately guilty about it. But when she saw all of the tattoos, she, for the first time at work, actually felt scared. She has seen National Geographic Lockdown and she knows that one doesn't get initiated into a gang by knocking mailboxes over or kneeling behind your buddy while another friend pushes him and makes him fall. No, gang initiation generally involves a more illegal activity. Like killing. And the time when one's children are taken into protective custody is generally not the time when one is thinking clearly. NewFNP isn't given to paranoia, but she did feel like she had foolishly placed herself and her clinic in potential danger. She called the social worker the following day to talk with her about this, but she just got a voice mail.

NewFNP went for a beautiful bike ride in a nature preserve after work yesterday. It's all single trails and fire lanes and deserted bunkers and really, really, really long hills. Fun going down, not so much going up. She got to the top of the hill and stopped. She looked out over the ridiculously beautiful view below her and attempted to prevent her heart from exploding and the lactic acid from melting her quadriceps and thought, "I am so lucky. I love my life."

NewFNP is sure that she is overreacting and that this guy will do nothing to further jeopardize his custody of his children, who he quite clearly adores. But she will listen to her gut if she is ever in that shitty position again. The answer will be no. Sorry, but no. No, newFNP will not aide and abet. She will wait to do the exam until the police arrive, but she will not take a child off the exam table and away from her father ever, ever, ever again.

The obstetrical history

When newFNP considers the perfect amount of children to have, she generally comes up with one number: two.  However, if newFNP does not get on the stick - so to speak - she will have exactly zero.

NewFNP's patients do not seem to share her values when it comes to parity.  Granted, newFNP has nothing but unfettered access to birth control and is also nursing a semi-paralyzing fear of parenthood.  Be that as it may, she finds the obstetrical history of her elderly patients who grew up in developing countries fascinating.

Today, she asked an 80-something year old lady how many pregnancies she had had.  Fifteen.  Fifteen.  How many births?  Fifteen.  Her vagina must hate her.  As is common with multigravid women in developing countries, some of her children did not survive infanthood.  Seven of her children died during the first year of life.  

It is not uncommon that newFNP's patients are grand-multips.  NewFNP has heard so many 10's and 12's and 14's when she asks about number of pregnancies, she is hardly surprised by the answers anymore.  But these women generally have some type of birth attendant with them.  Sister, mother, nurse, lay midwife, doctor... someone is generally there to assist in the birth.

One seventy-odd year old lady, however, gave birth alone.  Twice.  NewFNP was sure that she had misheard.  Alone?, she asked.  Alone.  No midwife?  No, no midwife.  Twice? Si, si, the patient assured newFNP with an amused smile on her face.

NewFNP's patient went on to tell her that she just had the scissors on hand, birthed the baby, tied off and cut the umbilical cord.  NewFNP's face must have betrayed her amazement.  Her patient explained that there was a woman in her community that gave her something to drink beforehand -- to give her strength.  What in the hell was in that drink and can newFNP get some of it before she goes to work on Saturdays at 7:30?

It's quite a contrast between prenatal care at the fancy hospitals here in the U.S. with ultrasounds at every visit and 3-D ultrasounds and CVS and amnio and EAFPs and episiotomies and forceps and fetal scalp monitoring and NSTs and epidurals and IV morphine and 25% or higher c-section rates.  NewFNP isn't saying that she isn't down for a little picture of the fetus action, but it is nice to remember that pregnancy and birth aren't diseases and that women's bodies are, in fact, designed to support the entire process.