Thursday, August 28, 2008

Gimme some sugar

NewFNP sees diabetes each and every day. Double digit A1Cs are, sadly, all too common. But she has very few patients who are as bad off as her 23-year old diabetic with an A1C of 15.7. The lowest A1C she has ever had since her diagnosis in 2006 was in the 13's.

Generally, during her all too infrequent clinic visits, this young woman presents with sugars above the limits of detection on the clinic's glucometer. Once, she came to clinic almost unresponsive in a hyperosmotic - hyperglycemic state (HHS) - mouth dry as a bone and in and out of consciousness. NewFNP sent her promptly to the ER. She passed out another time in the supermarket and again, was sent to the ER in HHS. This last time, she felt herself reaching that HHS point and called the paramedics herself. That's good, right? Understanding one's symptoms and acting accordingly. Sure, a little prompter intervention would have been prudent, but newFNP is feeling generous tonight.

She spent a week in the hospital and left with a glucose of 130, according to her discharge summary. She had prescriptions for insulin, but had not been able to afford the medication when she presented to newFNP's clinic the morning after her discharge.

Her glucose less than 24 hours after hospital discharge? HHH.

NewFNP got her to a detectable level after 30-something units of insulin in clinic, did insulin instruction, diet education and sent her to the nutritionist. This was not the first time in three years that newFNP did diet education, but it is the first time that, when her patient told her that she had eaten two tamales and some pancakes for breakfast, newFNP stated, "That is just like putting a gun in your mouth and pulling the trigger."


NewFNP has never been one to respond to or to employ scare tactics, but she cannot tell you how many people have told her that they changed a behavior because someone showed them a picture of a foot with an amputated toe or because they saw their friend suffer from and STD, etc. Others providers have told newFNP that they use the patient's fear of adverse outcomes regularly in their counsling. NewFNP has just always felt that that is an ugly tool. If newFNP's provider would have said something like that to her, she would have thought, "Whatever- screw you." But newFNP said it and saw that her patient heard it - for better or for worse.

OK, so pretty harsh. NewFNP is certain that the nutritionist delivered the message in a more nurturing fashion.

Whatever message stuck for this patient, it really frigging stuck because when she can into the clinic yesterday, her glucose was fifty-frigging-one. In the course of the six hours newFNP kept her in clinic, this young woman consumed a 75g glucola, a 4g glucose tablet, a turkey sandwich, salad, fruit, a second helping of glucola - this time only 25g - and, thanks to newFNP's awesome student, a chicken breast from El Pollo Loco (thanks BC!). During the course of the six hours, her glucose measured between 45 and 215.

What the hell?

NewFNP reviewed how much insulin she was using and if she was using it correctly. She was. NewFNP therefore lowered her insulin doses and have her strict instructions regarding glucose monitoring, ER indications and follow up.

NewFNP likes to be an outlier if it is something like 2 standard deviations above the mean in fashion sense or test scores, but she does not like glucose outliers on either end of the spectrum. And she isn't sure why this young woman is all over the glucose map.

And now she'll wonder about this patient as she spends two luxurious weeks on vacation after only one more eight-hour shift this Saturday. She'll have to hit up Dr. Dual-Ivy-League-Degrees for an update.

NewFNP's service commitment ended today. Her six-figure nursing school loans are forgiven. Now she only has five-figure pubic health school loans with which to contend. Aaaahhhhhh! What a relief.

Saturday, August 23, 2008

The final countdown

NewFNP's CEO signed her final loan repayment form yesterday.  Her last full-time day is one week from today.

There is not one part of newFNP that is sad to be leaving full time practice at her clinic.  And that makes her very fucking sad.

Provider burnout is not new.  Articles have been written, schools talk about it, practitioners live it.  And for what?  There is a lot of talk about a broken health care system in every media outlet to which one chooses to listen.  But it's not just the Medicare reimbursement or the HMOs and PPOs that are broken.  

It's organizations like newFNP's clinic - where the average shelf-life of a provider is less than three years; where there is not one hour - hell, there's not one minute - of administrative time scheduled for providers; where there is no one to follow up on referrals to specialists; where there is not one registered nurse, not one LVN, not one CNA; where providers work through lunch every day; where lab results, correct phone numbers and vital signs aren't in charts; and where patients are double and triple booked.

NewFNP is partially to blame for her own burnout.   But, you know what, her clinic is responsible as well.  It doesn't seem too far fetched to make efforts to take care of one's employees.  NewFNP's senior management believes that providers are just there to see patients, and as many as possible each and every day, all the while fixing the errors of other staff members, filling out endless forms and attempting to care for the physical and, often times, emotional well-being of the patients.

It's too much.  NewFNP isn't sure if it's her - if her lack of personal fortitude is the problem, or if it's the dysfunctional environment in which she works.  She thinks that, given her degrees from top schools, it's the latter, but it's not in newFNP's nature to let herself off the hook that easily.  Perhaps it just means that she needs to choose her next practice site more wisely, if she ever goes back to full time practice.  Perhaps she needs to impact health outcomes from a more hands off venue.  

NewFNP thought that she would be working with the urban poor forever.  She sought out a free health clinic in the frigging ghetto.  And now she wants to get the hell away from it.  That is sad

One thing newFNP can say is that she learned a lot these past three years.  And she continues to learn every day.  And that is a really lovely thing about nursing and medicine.  But when it's time to go, it's time to go.

And it's time.

Thursday, August 21, 2008

Hemoglobin of 6

For those not in The Biz, a normal hemoglobin in roughly in the neighborhood of 12-16 g/dL.  NewFNP is not going to lose any sleep over an 11 or even a 10, but she will assess your gender and diet and overall health and pregnancy status and miserable menstrual periods and history of hemoglobopathies, yada yada yada.  

No, newFNP doesn't go into real worry mode until she sees hemoglobins in the single digits and, really really not until it's below 9.  

But what will get newFNP's attention faster than a J. Crew shoe sale is a hemoglobin of 6.  And that is exactly what newFNP has seen this week.  


NewFNP's first crazy anemic patient is the 30-year old with AIDS.  He came in noting copious frank rectal bleeding times four days.  NewFNP saw him two weeks earlier and his hemoglobin was 10.  NewFNP placed him back on iron and instructed him to return to his HIV doctor.  He is taking the iron but is less adherent with his HIV care.  Some might say that his priorities are askew, but when your hemoglobin is 6 and you are bleeding from your rectum, newFNP doesn't have that chat with you.  She examines your bleeding after 5 minutes of hemming and hawing over the embarrassment about showing newFNP your b-hole, notes frank bleeding and transfers you to the hospital for transfusion and diagnosis of etiology.  

NewFNP spoke with his nurse at the HIV clinic a couple of days after his admission- he's hospitalized, transfused and recovering.  But, in reality, he is circling the drain.  He's failing his HIV appointments and taking his medications incorrectly and not taking all his prophylaxis meds.  It breaks newFNP's heart to see him suffering so much and to see him not adhering to his care.  Thirty years old.

The second anemic patient this week presented to clinic with vaginal itching.  She is 14 years old.  She wasn't with her parents because she's sexually active and doesn't want them to know.  NewFNP got her history and was about to begin her exam when she realized that she had forgotten to look at the lab section of the chart.  She flipped back and saw that the patient's hemoglobin was 6.1.  She asked the patient about heavy periods or dark stool or nosebleeds - nothing.  She thought that the MA must have made an error and asked her to repeat the test.  It was 6.3.

This brings newFNP to another point.  Both times, newFNP's MAs had no idea of the significance the very abnormal result held.  One MA is known to newFNP and she's not entirely surprised, but when newFNP expressed shock at the result and instructed him to repeat the test, he was in the patient's exam room, repeating the test in a fricking flash.  NewFNP saw the second patient in a clinic that is not her regular site as she was filling in for a provider who is on vacation.  Unlike the MA at newFNP's regular site, this MA did not seem very impressed with newFNP's instruction to quickly repeat the test.  Frustrating.  But it does bring to mind a few lessons:
  1. Repeat abnormal values.
  2. Work with the same MA so that you can teach him/her abnormal values that necessitate your attention.  The same MA who blew newFNP off when she asked her to repeat the hemoglobin also let a post-CVA hypertensive woman sit in the lobby for two hours after having recorded a blood pressure of 198/110.  NewFNP was displeased.
NewFNP called the fourteen-year old's mother, told her that her daughter wasn't feeling well and had come to our clinic where we detected this anemia.  Her mother told newFNP that she was anemic because she didn't take vitamins or eat well.  Hmm, not the most common reason for a hemoglobin of six, but very motherly, no?  NewFNP told her that her daughter might need a transfusion and could she please come to the clinic.  

NewFNP's big worry is cancer.  She's not sure if she'll ever know what happened with this young woman but she doesn't have a good feeling about this one.  

Friday, August 15, 2008

La cucaracha! La cucaracha!

There are a great many things that newFNP does not want in her ears.  Wall-o-wax and slurpy tongues come to mind, but much, much higher atop that list is anything on God's green earth that has an exoskeleton.

NewFNP had almost made it to three years of practice without having had to retrieve the dreaded cockroach from a child's ear.  Her perfect record was spoiled yesterday.

NewFNP's 14-year old patient came in with the complaint of three days of ear pain.  Generally, when a teenager has an OM, newFNP sees some distress, some fever and some lymph nodes.  This young lady had nothing but distress.  As newFNP manipulated her pinna to get a good look inside, she felt a good deal of distress as well.

At initial glance, newFNP just knew that something was rotten in Denmark.  She had never seen wax look so symmetrical.  "No," she thought to herself.  "Please, no."  She looked around a bit more and saw an unmistakably roachy leg -- a little spindly tibia with its little roachy projections just sitting there, taunting newFNP and begging for removal.

After years and years of evolution, why is it that these most dreaded of pests have not developed the ability to move in reverse?  And, when entering an ear canal, why do they not sense danger and just stop?  And, once in, why do they keep going?  They have both eyes and antennal flagellae!  What the fuck?

At any rate, newFNP was faced with a dastardly combination: traumatized, crying fourteen year old who was in physical pain (to say nothing of the emotional torment one must feel upon learning that your ear is a cockroach garage cum coffin); big roach parked deeply in the ear canal; and tiny freaking ear canal.

NewFNP attempted mechanical extraction but was categorically denied.  She then moved on to irrigation in an attempt to move that M.F.-er to a more reachable place.  At this point, her patient was close to losing it.  

NewFNP made a reach and removed... a thorax.  She looked inside her ear and could easily see tissue-paper thin wings wallpapering her patient's TM.  

OK, cockroach!  You win, you fucker!  You bested newFNP.  NewFNP set up an ENT visit for the afternoon and sent the poor girl on her way, half a cockroach nestled in her tiny ear.  


Wednesday, August 13, 2008

NewFNP is a jerk

NewFNP is reading an article about burnout and she sees herself in it far too frequently. 

She feels like an utter failure.  NewFNP hasn't really ever given up on something, but she is so relieved that she is giving up on her community health practice.  And she is so ashamed to feel such relief.  

But she is snapping at staff members (irritability) , she feels burdened by patients (frustration) and notices that she feels less compassion in the exam room at times (apathy), she dreads going to work (despair).  

In retrospect, she should have taken more vacation.  But she has coping mechanisms and she uses them.  They just don't work anymore (emotional exhaustion).   

To newFNP, that all screams failure and the cumulative effect is breaking newFNP's heart.  This is not how she wants to behave and feel.

Two more weeks.  Hope springs eternal for newFNP -- she hopes that when she is working part-time, she won't be such a huge asshole.  Can she just stay in bed for the first two days of her two-week vacation?  Can her friends and family gather at her bedside and bring her Lucky Charms?  Will a facial and a peel brighten her outlook?

NewFNP hopes so, because she wants the old newFNP back.

Monday, August 11, 2008

Phone-y baloney

There are maybe two cell-phone conversations which newFNP would like to overhear.  

One goes like this, "Hey Brad Pitt, this is George Clooney calling.  I am absolutely awestruck by the beauty and witty repartee that I have been enjoying with this lovely NP sitting in front of me.  I do believe that I shall fly her to Lake Como on my private jet and bed her."

The other may be something along the lines of, "What - they are giving away free flattering Theory trousers and cashmere sweaters at Bloomingdales at exactly 5:00 today?!?!"

What newFNP does not want to hear is your bullshit whatever conversation while she is attempting to get a health history on your two-year old kid during his physical exam appointment.

Can you hear newFNP now?  Hang up your goddamn phone!!!

For a solitary in-exam-room-phone-pick-up that is quickly ended with the words, "I can't talk now -- the newFNP is in the room," newFNP grants you a pass, but is nonetheless displeased.

After the second, third and fourth times, newFNP believes you to be unacceptably disrespectful.  During the fourth call, as the patient's mother was repeating an 800-number and credit-card number to the woman on the other end of her phone, newFNP exited the room, stating that she would return when the mother was more ready for the exam.  As she opened the door to leave, she overheard the mother stating, "Look - you made the newFNP leave" to the person on the other end.

Come again?  The woman who called - not knowing that the mother of the patient was in the exam room - bears responsibility?  No, ma'am.  

Sorry, sister, but one is not obligated to pick up the stupid phone while the provider is in the exam room.  In fact, one should be obligated to put the damn thing on vibrate or turn the fucking thing off after the first time it disrupts the clinic visit.

For the love of all that is holy, how do people not know this?  

Saturday, August 09, 2008

911 on speed dial

EMS presence has been a regular feature are newFNP's clinic recently.  The trend started last week when newFNP had two ambulances at the clinic at the same time - a first for newFNP.

NewFNP's first ambulance-requiring patient was a depressed woman.  She came in complaining of headache, but her affect screamed depression.  As it turned out, she had two suicide attempts requiring hospitalization last year and was suicidal again.  She had a plan (run out into traffic) and means (busy urban area with lots of traffic).  She didn't trust herself to leave clinic and go to a psych appointment the next day.  She wanted inpatient admission.  

She got it.  

NewFNP called her local psych response team at 1:30.  She kept her patient in the room, supervised at all times.  The 'team', which was comprised entirely of one gentleman, arrived at 5:15 PM.  That is when he began his assessment.

NewFNP is a strict believer in not having anyone be alone in the clinic after closing, given that when the lights go down, the sex workers and drug dealers and rival gang member come out.  Adopting a team player attitude, and possibly to get out of his sister-in-law's wedding planning activities, newFNP's clinic manager agreed to stay with her until the psych patient was safely escorted out.  NewFNP and this 24-year old guy were just sitting around when he decided to take a peek outside and find out just where in the hell this ambulance was.  

He returned, clutching his head and telling newFNP that he needed the O2 mask.  Having had a mock code the day before, newFNP briefly thought that he was kidding.  

He was not.  He told newFNP that he had 'blacked out' and couldn't feel his left hand.  He was clutching his left parietal area and complaining of intense pain.  

At this point, newFNP had the suicidal lady and her mental health assessor behind closed doors in room 3, the clinical manager in the lobby and the custodian somewhere in the clinic.  NewFNP quickly assessed the manager, yelled for the custodian and ran to get the emergency equipment and called 911.  

The fire department arrived for the clinic manager at the same time that the first ambulance arrived for the suicidal lady.  It was 6:15.  The second ambulance, expecting to transport the clinic manager to the ED, arrived at 6:25.  NewFNP's clinic manager was hooked up to a portable EKG, normoglycemia confirmed, Romberg negative.  The suicidal lady, much more relaxed, was strapped into her ambulance gurney and departed for her psych evaluation.  

At 6:45, a handsome paramedic asked newFNP, "What time does your clinic close?"  "Five," newFNP replied.

At 6:50, newFNP's clinic manager decided, to newFNP and the paramedics' protests, that he'd prefer not to go to the emergency department after all.  

NewFNP and six firemen/paramedics can lead a horse to water...