Thursday, October 30, 2008

More Mirena

Again with the Mirena hatin'!  Different patient, of course.  NewFNP is trying not to take it personally.

Clearly newFNP needs to do a neurology CME to try to understand why the brain would cause a normally reasonable enough woman conclude that her headache of three days duration had its etiology in her IUD which newFNP placed a full five months ago.  

And then, what stops someone from just popping a Tylenol or two?  NewFNP finds this to be such an irony in her clinical population.  No one hesitates to borrow a penicillin or a couple of tetracycline when they have a cold or eczema or whatever.  But to take an over-the-counter analgesic - not gonna happen.  Better to just head on into the free clinic and get some Tylenol there.  


Friday, October 24, 2008

Back that ass up

NewFNP got totally bitch-slapped by the universe.

Two months ago, she placed an IUD in a 38-year old G7P8.  This woman was certain that she was done with childbearing and that the IUD was preferable to a BTL.  NewFNP is privy to this woman's complicated social history and agreed that an IUD was a good choice.  We reviewed adverse effects and benefits, signed informed consent and went for the placement at the next visit.

The insertion went smoothly, as one might expect with a woman who has had 8 vaginal deliveries - even of her twins.   That was the last smooth experience newFNP has had with this client.

The next day, she returned to the clinic stating that she wanted newFNP to remove her IUD.  She had read the entire pamphlet and was disturbed to learn that women may have tubal pregnancies with the IUD.  Yes, newFNP explained, but women are at risk for ectopic pregnancies anyway and lowering your risk for pregnancy also lowers your risk for tubal pregnancy.  While her patient was surprised to learn that women could have pregnancies outside of the uterus, she was nonetheless unsatisfied with the IUD and wanted it out.  

NewFNP said no.  

She encouraged her patient to give the IUD some time, to think about the risks to her family and to her mental health, to say nothing of the AMA-related risks, if she were to have another pregnancy.  NewFNP told her to give it 3-6 months and if she was still unhappy, then we would again talk about removing the IUD.

She has been back three times since then.  Twice, Dr. Dual-Ivy-League-Degrees told her the same thing.  The third time, the new all-around-feather-ruffling doc told her to come back in a week and someone would take it out.  

She showed up the next day and waited for five hours for her three minute IUD removal.  NewFNP was all bunched up about taking it out and thought it would be a good learning experience for her PA student to take out the frigging thing.  

Before everyone gets all up in arms, 0f course this patient has the right to use or not use whatever family planning method she would like to use.  Of course she can have as many pregnancies as she wants to have.  But she doesn't want to be pregnant and she hasn't exactly excelled at contracepting in the past.  And now she wants to use "gel" to avoid pregnancy.  What?  Gel?  Like hair gel?  Gonna put some TRESemme up there?  Gel???  What about a fucking condom??  The pill?  The ring?  The patch?  The shot?  A diaphragm?  A tubal ligation?  There are many effective methods but gel, sister, is not one of them.

So newFNP did some alternative method counseling and got her student set up to remove the thing, fuming inside about this utterly failed attempt at decent, reliable contraception and feeling a little pissed that she was taking the IUD out.  As she maneuvered her student's instrument tray, newFNP backed up - ass-first and slightly bent over in order to visualize what her student was doing - and hit her butt on the corner of the counter in the exam room.  

Oh, the velocity of her movement.  NewFNP does not know her own strength, even when conducting a seemingly benign activity like backing up.

A shockwave ran down her leg and up her spine.  She wanted to cry out "Mother fuck!!!" but she didn't want to entirely destroy the already shaky encounter.  If this were a different kind of site, newFNP would post a picture of the impressive purple bruise that has caused her untold pain and has served to remind her about that shithole of an encounter and that her patient can do whatever she wants for birth control, that it's newFNP's job to educate, guide, encourage and prescribe, and that she should just keep her judgments to herself and take that fucking IUD out and move on.  

NewFNP knows all of this but she does want to point out that this IUD costs around $500 and that its cost-effectiveness is really not seen when someone has it for two freaking months.  

Thursday, October 23, 2008

Got Gardasil?

NewFNP had two HPV-related teen pregnancy issues today.  Both were really sad and unsatisfying, both to her patients and to herself.

NewFNP's first HPV lady is a 16-year old 259-pound 35 weeker.  She has gained 47 pounds this pregnancy, far surpassing the 0-15 pounds newFNP recommended at the outset.  At pregnancy diagnosis, she had chlamydia and a low grade lesion on her pap.  NewFNP referred her for colposcopy - she didn't go.  She was scared, which is understandable, and her mom counseled her against going, which is less so.

After several visits of encouraging her to get the colposcopy to no avail, newFNP said fuck it and repeated her pap, hoping that her youth would wrestle that HPV into submission and normalize her pap.

Alas, it's now a high grade lesion.  

NewFNP resubmitted the colpo referral, acknowledged fears, stressed patients' rights and informed consent and strongly encouraged this young woman to not blow off this evaluation.  

The second 16-year old HPV lady also had chlamydia at pregnancy diagnosis and has recently been diagnosed with external condyloma acuminata, or genital warts.  You may recall newFNP noting how she had newFNP pulled out of the exam room to share this "emergency" with her.

She returned to clinic today, concerned that she had a yeast infection.  NewFNP placed her in the lithotomy position, noted the external warts - which now seem quite petite - and placed the speculum.

What greeted newFNP briefly forced her to consider that her knowledge of the female genital anatomy was really, really inadequate or like maybe she was in the wrong body cavity - a cavity she has never before seen.  The exam begged the question: what percentage of the surface area of the vaginal and cervix can be covered with condyloma before one considers c-section?  

Greater than fifty percent?  Seventy-five?  Fifty percent vag, fifty percent cervix?  This is something that is not in newFNP's textbooks.  It is likely something that one picks up from a wise mentor with years/decades of OB/GYN experience or years of your own OB/GYN clinical experience.  

NewFNP knows that there is a chance of extensive laceration and poor ability to suture the lesions during a vaginal delivery.  She assumes that this risk is increased when one's cervix is almost unrecognizable due the presence of extensive large verrucae.  And then, once the baby exits the cervix, it must make its way down the cobblestone canal-o- vaginal warts. 

Baby, keep that little toothless mouth closed!  Not that laryngeal papillomata are so common, but newFNP is just sayin'!  An ounce of prevention, ya know.  

As newFNP does not do deliveries, she arranged a consultation with the team that does.  

These young women just can't catch a break.  They have fucked up lives, fucked up parents, fucked up partners (neither of whom stuck around to support these girls during their pregnancies) and multiple STDs.  

And they're 16 and pregnant.  Mercy.

Monday, October 20, 2008

Dutch treat

NewFNP is in a bit of a pickle.  

You see, newFNP really values cute shoes.  But her plantar fasciitis is killing her.  And delicious though her sweet J. Crew Liv flats might be, they offer her no support at clinic.  And for the love of Pete, she can't wear her Cole Haan/Nike numbers each and every day!

So newFNP has been doing some thinking.  A long-articulated goal is a life of physical activity.  Sure, she tore her ACL and has a knee chock-a-block full of arthritis.  No worries - she'll just stay out of the snowboarding jump parks and enjoy the serenity of the smooth, long runs and maybe just take a little hop here and there.  And, yes, it's true that her mid-tibial tendinitis did get so severe that her physical therapist threatened to put her in the boot.  As if.  OK - so she has sacrificed her running and would now be hard pressed to run a mile although, truth be told, she hasn't recently tired.  But she wants to, goddammit, how she wants to!  And now with the fucking plantar fasciitis.

Well, she's thinking of returning to the supportive arches of the Dansko clog. Oh sweet Jesus, she feels a pang of sartorial resignation in even thinking it.  But BostonFNP wears them and looks so smart.  Dr. Dual-Ivy-League-Degrees looks cute as a button in hers.  

But newFNP will just feel like a big frump.  This is why newFNP is totally pathetic.  Who gives a fuck if she looks Dutch frumpy at work?  Only newFNP cares about that.  But she might just buy those fuckers anyway because she does not want bunions or plantar fasciitis or heel spurs or any of their associated surgical or aesthetic sequelae. 

If she goes with the patent leather option, that could be cute.  Right?  Maybe even with a new pair of AG jeans, right?  


Thursday, October 16, 2008

Research + Clinic = Perfect Situation

NewFNP is going to let you in on a little secret: she likes clinical practice more than research.  That could be because newFNP has an inherent distaste for all things new or it may be because the research clinic is in a slow-as-molasses phase, but newFNP is - and boy does it ever pain her to say it - bored. 

That being said, newFNP was about to stroke out today when she had already seen 17 patients before high noon.  Or when her 16-year old pregnant math whiz had her pulled out of the exam room to talk to her about an emergency - genital warts.  

But she loved it when her absolute favorite patient, a 6-year old boy, ran down the hall to give her a big hug, show her his missing tooth and proceed to chat her up about Spongebob and Patrick and show her his perfect penmanship and numbers.  And it made her feel really useful when her 30-year old pregnant patient, who had been tearful in the exam room due to problems between her and her baby daddy, dropped newFNP an e-mail, letting her know that she was doing OK and would be in to see newFNP next week.  

NewFNP is making connections with her study patients as well, but there are three of them and newFNP works for eight hours.  Three patients, 8 hours.  Thirty-three patients, 8 hours.  For the love of sweet baby Jesus, can newFNP find a happy freaking medium?  

Anyway, making these new connections and valuing her continued connections with her clinical patients is really quite lovely.  It does bring newFNP a feeling of doing good for her community, for her individual patients and for herself.  NewFNP set out to be an NP because she wanted to have a meaningful career which brought her joy and promoted wellness in the lives of others.  Burnout sort of negated all those philosophical whimsies that newFNP had articulated for herself.

So, in sum, newFNP supposed that her current combination is working for her.  Bored or not, she does love going into work at noon three days per week.  This affords her the opportunity to go to Weezer concerts mid-week with her BFF and not be exhausted the next day.  It allows her to peruse chic glasses frames and ultimately decide on a sweet Kate Spade pair ("Elisabeth" in case anyone wants to be twinsies) with all the time in the world, nary a care in her mind except which glasses are going to make her look like a smart and sassy.  And thank goodness she has the time to exercise because her research job is largely sedentary and newFNP wishes to prevent work related ass spreading.  

And working part-time in clinic cures burnout.  It took a while for her pseudo-PTSD symptoms to subside but now they have.  

NewFNP just doesn't feel fried anymore.  

Thursday, October 09, 2008


In newFNP's clinic, we are sticklers for identifying prenatal depression.  God help you if we diagnose it, but damn it all if we don't assess for it at bloody every visit!

The manner of assessment is a form called the PHQ9.  It is a series of nine questions developed to elicit depression via a Likert Scale of 0-3.  Generally, the patients fill it out as they wait behind closed doors for their provider.  Sometimes they tally the score; other times they leave that piece to newFNP.  NewFNP is cool with it either way as it takes her a nanosecond - plus or minus - to tally the thing.

This is sort of what the PHQ9 looks like:

I feel tired.   0      1      2      3

I have less energy than usual.            0      1      2      3

My appetite has changed.                   0      1      2      3

... and then six more questions.  Zero means not at all, three means quite a bit.  

Easy peasy right!?!

At the bottom of the page, there is a space to tally up one's result.  It looks like this:

______ + ______ + ______ = ______________

Makes sense, does it not?  Add the column directly above and write it down.  Then, add the three totals.  

So today newFNP looked at the PHQ9 of a 16-year old pregnant woman with a not altogether ideal social situation and saw 6 zeroes, 2 ones and 1 two.  Not too bad!  This young woman did the tallying herself and it went a little something like this:

___6___ + ___2___ + ___1___  = ______________

Is everyone with newFNP?  Six zeroes = 6, two ones = 2 (correct) and one two = 1.  Hmmmm.  Now, newFNP understands what she was doing, but what this young lady misunderstood is that we are looking for a cumulative score rather than for the frequency with which each answer appears.  

Then, rather than adding left to right, this lady did math the old fashioned way.  On the side of the paper, she had written:


Not 6 + 2 + 1.  62 + 1.  And newFNP though that she had mathophobia!

Grand PHQ9 score: 63.  On a scale of 0-27.

In newFNP's institution of education, we spoke frequently of scaffolding our pediatric and adolescent patients who were experiencing stressful times, illnesses, etc.  NewFNP does a fair amount of scaffolding with this client - much more so than with her non-adolescent prenatals.  But she is not sure that there is enough scaffolding in the world to counteract the effects of limited IQ and a fucked up social situation coupled with the impending birth of a child.  

Sunday, October 05, 2008


NewFNP wants to say right off the bat - take that O.J., you murdering, armed robbering, kidnapping motherfucker!  Sure, you got away with murder, you SOB, but you couldn't just walk the straight and narrow and the good people of Las Vegas were wise enough to do what the people of Los Angeles could not thirteen years ago.  NewFNP supposes that murdering two people loads you up with bad karma.  Further felonies do not help.

OK, back to newFNP.  In her new job, newFNP is surrounded by overachieving braniacs.  Hell, in her clinical job as well, but in her clinic most people are content with providing clinical care.  In her new job, clinical care is part of what you do when you aren't taking an 8AM course in genetics as a fun refresher or being a RWJ Clinical Scholar or writing new research proposals.  NewFNP is in the fucking thick of academia in her new gig.

To newFNP, academia is like her fantasy world of smart people just getting to be smart and do smart things and make smart geeky jokes about acetylcholine and dopamine.  It's where miracles happen - where genomes are sequenced and viruses are isolated and treatments are cutting edge.

So newFNP really has a lot of opportunity to grow in her career.

The thing is, newFNP isn't sure how much she wants that anymore.  Sometimes newFNP just wants to read Go Fug Yourself or For Whom the Bell Tolls or the New Yorker.  Sometimes she just wants to get her teeth whitened or her face facialed.  She wants to go to a movie or a Weezer concert or the opera.  Or she wants to write here on her blog, which she fully acknowledges is not advancing the science in any way but brings her a lot of joy.  And what if she wants to have a baby one day?

Recently, newFNP's new supervisor mentioned that he hasn't been to a movie in years.  Incredulous, newFNP asked why.  He stated that he doesn't have time.  No time?  For a movie?  Not even for a George Clooney movie?  That is not the life for newFNP.

And newFNP feels a little guilty about this.  Like she is letting her new boss - of three weeks - down.  Like she isn't living up to her potential.  Like she is a big flake for not taking on more and more responsibilities.  

But, for now, she'll just go read some Hemingway and put her professional neuroses to bed for one more night.