Put this baby to bed

NewFNP was on her way to work today and was wondering why her steadily moving flow of traffic came to a grinding halt. When she got to the intersection, she saw a person laying in the road with a woman kneeling by her side. NewFNP stopped, noted the decent sized pool of blood under the woman's head and checked for a pulse. Thankfully, there was one and the woman was responsive. She waited until the paramedics -- the super hot paramedics -- arrived and basically put the ky-bosh on well-meaning bystanders trying to move the woman who had been hit by a truck.

That's a hell of a way to start one's day. One minute, you're crossing the street and then next, you're slammed into the pavement.

That's what 2010 has felt like for newFNP and she is ready to put this piece of dump year to bed. Two thousand and ten has been for the motherfucking birds.

NewFNP went about her day, sent a pregnant patient to the hospital with fetal tachycardia, treated another's chlamydia, et cetera, et cetera, and then got a message from the title company that her grandmother's house is in escrow.

NewFNP should be happy about this, what with this economy. She is trustee of the estate and has been wanting to get the home sold for some time now. Selling the house will help newFNP to continue paying for her grandma's care.

But newFNP is a little sad. NewFNP's three-year old footprints are in the cement of that backyard. Footprints from the seventies. NewFNP and her grandma made newFNP's prom dress there. NewFNP has quite literally a lifetime of happy memories from that home -- which, by the way, was built in 1962 and has one of the glorious pink bathrooms featured in today's NYT.

In the past month, when newFNP has gone to visit her grandma, it's clear that her grandma no longer recognizes her -- she just stares ahead as though she is still alone.

The selling of that house feels like the end.

Dis-gusting!

No Monday could be worse than last Monday when newFNP took one to the kisser.

But newFNP had a close second in terms of building her case against Mondays. (And this Monday is in the shadow of a three-day weekend and a newFNP cumpleaños so bitches better start coming correct!!)

NewFNP was going about the same old business of performing a pap. Using her gentle touch, of course, she grabbed an endocervical sample with the cytobrush and, upon removal, noted a viscous, gloopy, stringy mucous hanger-on. Not wanting it to drop, newFNP began an attempt to loop it around the brush using a circular motion.

No luck. A glob of it was hell bent on attack and launched itself Pyongyang style, landing directly on newFNP's forehead.

Fucking. Disgusting.

But newFNP felt like she lucked out by not having that shit land in her eye. She brushed off the attack, literally and figuratively, and went about her day.

Hit me with your best shot

NewFNP has had better days at work.

To begin with, newFNP's back is jacked up and she is walking like she has a stick up her ass. Then she saw 17 patients before lunch.

Then her last patient hit her in the face. Open hand, but with the force of 202-pounds of mother-fucking crazy behind it.

NewFNP has never, ever been hit before. She is a white girl from the suburbs who went to top tier schools and watches Jon Stewart and goes to spin classes and shops at J. Crew. She does not engage in fisticuffs. And, quite frankly, she could go the rest of her life without ever being hit again if she has her way. It hurts. NewFNP was actually dizzy. And she was completely fucking shocked.

After her patient was forcibly removed from the clinic 5150-style and newFNP spoke with the officers about her being a victim of battery (not her words, but noted on the very official police report), she was told that she should go home for the rest of the day.

No shit.

It's one hell of a way to get half a day off, but you don't have to tell newFNP twice to get the hell out of dodge. Why couldn't her patient unleash the crazy at 9 AM instead of at 12:30??

Hipst-astic!

If there is one thing that newFNP sees very infrequently at work, it's white people. And today newFNP had a white hipster (subtype 70's-inspired) in her exam room.

He looked as though he had rolled straight out of Williamsburg on a fixed-gear skinny-tire bicycle while listening to Deerhunter and had somehow managed to end up in newFNP's clinic via some kind of fashion/anti-fashion vortex.

He had many of the markings of hipsterdom:

- shaggy hair-do and beard

- tan corduroys and a plaid tan & white shirt a la Oliver from the Brady Bunch

- American Spirits

- canvas Aasics

- a college degree yet a job at a camping store (possibly related to the economy and not hipsterdom)

- understated ennui.

How did he find newFNP's clinic and end up in newFNP's exam room to discuss the communicable scourges of scabies and HPV? After all, her clinic is in a very non-hipster and seemingly ungentrifiable area of town.

In his honor, newFNP is listening to her Hipster Harvest Mix CD, courtesy of her BFF, and laughing once again at the hipster dinosaurs.

Tech Talk

As we all know, the DSM is getting a do-over. As the NYT pointed out today, narcissistic personality disorder is on the chopping block.

Well, newFNP can help pad those empty pages. She is here to offer a new criterion for "psychotic disorder NOS" that should make it into the new psychiatry bible.

NewFNP is a fan of technology helping her out throughout the course of her workday. Where would she be without her iPhone and its BMI calculator, its OB wheel, its ICD-9 coder and its access to her gmail account so as to enable newFNP to track her online package shipments while at work? (Damn you, Madewell, and your cute new sweaters for 25% off!!) NewFNP's clinic is en route to electronic health records and newFNP is very much looking forward to forgoing the search for a decent black pen every day.

But these technologies are not those of interest to newFNP in regards to her hypothesis of how technological advances are shaping the scientific and clinical milieu.

NewFNP has noted time and again that people who are somehow psychotic attribute profound significance to the shitty photos snapped on their cell phone cameras.

NewFNP has seen many, many a flip-phone and Blackberry image and has been told that the image in the blurry photo of a sex partner was the aura of a snake, that there was a hand coming out of someone's head, that there were angels reflected in the mirror. In each and every photo, newFNP saw essentially the same thing -- a crappy, blurry cell phone picture utterly lacking in reptiles, odd appendages or the supernatural. And she can say definitively that the more expensive phone did not take a better crappy ass picture.

In one patient, newFNP gently asked if anyone had ever told him in the past that he may have a mental illness? No, he told newFNP, he was a Christian and he had burned the curtains in the living room after having sex with the snake-aura partner in order to purify himself. His response did not diminish newFNP's concern.

Perhaps the criterion can be "On at least three of the past seven days, the patient has engaged in excessive cell-phone photography (excluding those on iPhone 4 with flash and photography apps) and has inappropriately placed religious or spiritual significance on the incomprehensible images attained."

You're welcome, APA. You get that one for free.

Family Tradition

The first time newFNP saw positive cerebellar findings in a chronic alcoholic, she thought that the patient had misunderstood her instructions. Not that rapid alternating movements (RAM) are so hard to describe, especially as newFNP always demonstrates said movements, but -- you know -- maybe the patient just missed the boat.

In retrospect, she shouldn't have been surprised. This patient was a middle-aged man who walked as though he was an epileptic zombie. Yeah, that gait ataxia is a good first clue. (This video of a professional man in pleated Dockers-style pants demonstrated a pretty great example of ataxic gait and, frankly, is kind of hilarious.)

Yet, newFNP was astonished to see the floppy-fish movements of the RAM. When she moved on to finger-nose-finger (at a arm's length away of course -- any yayhoo with half a cerebellum can make reasonable contact as less than full extension), she felt lucky to have left the room unblinded. She didn't even conduct a Romberg as she felt concern for the patient's safety.

That was about a year ago when newFNP was in the research clinic. That patient did not matriculate into the study.

Today, however, she had a patient in his mid-40's who began drinking at the age of 12 when his drinking buddy was his father. Having just been released from jail, he came to see newFNP to refill his diabetes meds. The last time she saw him, newFNP noted that he smelled of alcohol. This time, he lacked the aroma but exhibited the slurred speech one might note with acute intoxication. The dysarthria reminded her of her patient with cerebellar ataxia some time ago. His neuro exam confirmed newFNP's suspicion of cerebellar injury.

Now, newFNP loves her wine. And her mojitos. And her Maker's Mark with ginger ale. Wait -- where was newFNP going with this??

Ah yes, alcoholism is truly devastating. This man cannot work, he is in and out of jail and his father died from the disease that is killing him as well. The last two times newFNP assessed his readiness to change his drinking behavior, he was very clear and straightforward -- not ready, not yet. Since leaving jail this time, he has been drinking very little. He states it's time to get straight.

It's just too frigging bad that his cerebellum has been pickled before he came to that decision. Perhaps he will see some improvement if he can achieve some sustained abstinence. Until then, newFNP gives him his multi-vitamins. Today he got prenatal vitamins -- they were all newFNP had to give.

For other clinicians and students out there who need help getting substance abusing patients into care, the SAMHSA Treatment Locator is super helpful.

Grammar

Once upon a time, when newFNP was a younger lady and a new MPH student, the most influential professor of her life taught her a valuable lesson: data are plural.

This is certainly one of the least important lessons she learned from this professor from a public health perspective, but is one newFNP very commonly reflects upon given the frequency with which it is ignored. It has served newFNP well over the years in her academic writing and conversation, but it has also served to drive newFNP to drink when she all too frequently hears public health and medical professionals say "The data is..." It's like nails on a mother-effing chalkboard to newFNP.

As newFNP was sitting in her providers' meeting today (number of productive minutes = 7; number of minutes = 120) and hearing the noun-verb mismatch over and again, she was thinking to herself, "Thank you, SBS, for preventing newFNP from committing this academic faux pas... and thanks a lot!"

Do that voodoo that you do

One of newFNP's struggles is to work within a culture that is so utterly different from that of her own. Generally that manifests in requests for disability paperwork or in the dramatic vocalization of pain.

However, this struggle became uniquely salient today as newFNP was completing a physical on a 41-year old man. While he has a partner and family in his home country, he has been in the U.S. for twelve years and has a partner here as well. Apparently, his original partner was none too pleased because, as he told newFNP, she put a curse on him in order to make him impotent.

And dammit, it worked.

Now, newFNP might have taken an educational trip to a forbidden island in which voodoo is practiced and she might have entered an apartment which was protected from the evil eye by a special red fabric and was receiving some kind of power from a chicken with its legs bound by a red cloth, but that is as much as newFNP knows about witchcraft and black magic and voodoo -- which is to say she knows nothing. At her fancy nursing school, they wanted to teach the students frigging Reiki, but not even an elective on traditional/cultural medical practices/voodoo? Way to be culturally competent.

NewFNP could find no physical health concern that would explain this young, fit man's ED. From his perspective, his health was non-contributory.

NewFNP probed for a psychological explanation. Was he perhaps feeling guilty for having another partner here? He stated without equivocation that he was not.

(Hell, who can blame a dude for finding another lady after twelve long years? NewFNP is having a dry spell that nowhere near approximates that - thank god - and she's considering some recidivism.)

She asked him if he would like to try Viagra. He did not, because as he explained, the problem rested in the curse.

Not sure where to take this encounter, newFNP asked him if he believed that her curse was the only cause of his erectile dysfunction. He was certain that it was. In that case, newFNP told him, it seems as though you need to find someone to reverse that spell.

And for that, newFNP is hard pressed to recommend a single practitioner.

Thanks, but no thanks

It was placenta. The patient is fine albeit somewhat peeved.

In her follow up visit, she told newFNP that when she first felt something falling out of her lady business, she called her husband into the bathroom to survey the scene as she was unable to see beneath her newly post-partum abdomen. He confirmed that there was, indeed, something gone quite awry and that there was most certainly something alien in her nether regions.

"Pull it out!" she instructed him.

He declined and, instead, brought her into the clinic.

For those who are interested, the AAFP has a decent article about how to evaluate whether one has actually accounted for the whole thing. The article is a bit old, but newFNP doesn't think that the placenta has changed much in the past twelve years.

Contingency management

NewFNP deals with a lot of vaginal complaints. They generally run along the lines of itch, olfactory woes or a forgotten objet causing distress and/or one of the aforementioned concerns.

What is exceedingly uncommon (n=1 in five years) is for a woman, three days post-partum, to present to clinic with a chief complaint of "something is coming out of my vagina." NewFNP had two differentials: retained products or prolapsed uterus.

As newFNP and her patient assumed their respective positions, newFNP briefly thought, "Holy mother, is that an umbilical cord??" before coming to her senses. What she saw was a shiny, slimy, veiny mess with a decent sized clot in the middle of it, discovered only by digital exploration of said mess. NewFNP admits that she was surprised at the absolute lack of vaginal bleeding given the situation.

"Placenta," she thought. "Now what?"

NewFNP gave the protruding mass a gentle tug. Nothing moving and no pain on the patient's end. A slightly more forceful tug elicited movement but nothing spectacular. At this point, newFNP brought in Dr. Dual-Ivy-League-Degrees for assistance. While newFNP maneuvered the speculum around the protruding mass, Dr. Dual-Ivy-League-Degrees tugged with the ring forceps. Again, nothing. Not wanting to cause a hemorrhage and noting increased vaginal bleeding and that the patient's pulse was 120, newFNP and Dr. Dual-Ivy-League-Degrees stopped their efforts and called for an ambulance.

NewFNP probably could have handled the entire situation alone, but was just too uncertain. If the patient had been hemorrhaging and had something protruding from her vagina, that is an entirely different call: get whatever is causing the problem OUT. But this was different and newFNP just hasn't managed post-partum complications such as this in the past.

What a great learning experience for newFNP, both in learning about the actual care of this patient and of trusting her knowledge and feeling confident in her care.

Hasta la vista, toenail!

For five long years, there has been nothing that brings the quease to newFNP's stomach more than the very thought of removing a patient's ingrown toenail. NewFNP has used evasive maneuvers to avoid having to learn the procedure thus far, but now that she's signed on for another two years in the trenches (two months down --holla!!), she figured that she might as well jump in completely.

So she took off a toenail today and it was just as gross a procedure as she had expected. It is very tactile in that the remover can feel the nail tearing from the bed via the kelly clamp. And that tactile sensation did nothing to quell the quease. To top it off, newFNP can only imagine how awful it must be to have the procedure done and that made her feel even worse.

But she didn't pass out or barf on the patient's foot, so newFNP is content to call the procedure a success.

Consumption

The New Yorker is tailor-freaking-made for newFNP this week. A Talk of the Town piece about Pavement (you can bet newFNP has her tickets!!), an article about FB, another about Tavi and an article about J. Crew!! When in the world will she find the time to watch Sons of Anarchy??

But newFNP's life hasn't been all fashion and literature and hot, swaggering, conflicted motorcycle club VPs.

She has blissfully received one day of pediatrics and women's health in the midst of her grueling internal medicine and outpatient OB schedule. Except that life is not to blissful when one sees a 22-month old kid -- in the U.S. for four days -- with hemoptysis, such that his little jeans are covered with blood, and right apical rales that are gurgling to beat the band.

He had been in clinic two days prior and had been treated for a severe stomatitis. While the mom did note that he had the hemoptysis, the other provider treated the stomatitis and placed a PPD. The PPD was, as one might expect, stunningly positive.

It was no great stretch for newFNP to mask that sweet boy and send him to the emergency room after explaining her concern for active TB to the mom. And, of course, there this little boy remains, on oxygen with fulminant TB. It's hard for newFNP to imagine that those apical rales weren't present two days prior, but it's always easier to see things clearly in retrospect, is it not?

Mondays with Grandma

NewFNP's grandma is ninety-five. She has been demented for quite some time and this makes visits with her really difficult.

But lately, her health has been worse and, conversely, her cognition has been clearer. It's a gift to newFNP, but makes newFNP wonder how much longer she has. Last Monday, newFNP was snuggling with her and crying when her grandma pointedly and caringly said, "Honey, I don't want you to cry for me."

Today, newFNP was holding her hand when her grandma looked into her eyes, tears rolling down her smooth cheeks and said, "It's too hard to... it's too hard to..."

NewFNP said asked her what was too hard, even though she knew.

"It's too hard to say goodbye," her grandma whispered and then closed her eyes.

And it is. It is a fucking nightmare to say goodbye to someone you love so dearly, ninety-five years old or not. As her grandma slept, newFNP spent hours quietly sharing memories, offering words of peace and watching the gentle rise and fall of her chest. She held her hand and kissed her forehead before she left for the evening.

Bon anniversaire!

NewFNP celebrated five years of being newFNP today by hitting an 8AM spin class -- her first spin class in a year. Yowza.

A lot has changed in these five years. All of her friends from nursing school are married and most have kids or are pregnant (hooray nycPNP!!), whereas newFNP is bordering on cougardom. She has lost some of her closest loved ones and has gained others. She has visited three new countries, had three major hair-do changes and is on her third car.

But newFNP's most significant change is that she is confident in who she is as an NP. She is continually challenged by her patients, by working in community health and by keeping herself well while working in a dysfunctional environment.

But she is learning and she is capable. Just this week, newFNP diagnosed erythema nodosum and nephrotic syndrome -- both just known of but never seen differential diagnoses until now. That feels quite good. She saw what she thought might just be chancroid, which to hear newFNP's patient tell it feels not at all good, but might feel better after a change from acyclovir to azithromycin.

Now all newFNP is left to contemplate is where is this little endeavor -- the one you are reading -- going to go next?

Thank you sir, may I have another?

Remember the joy newFNP felt when she received her letter of completion from NHSC? Lord have mercy, she signed on for two more years. By the time newFNP finishes her loan repayment contract, she will have had seven crazy years at her community health clinic and $50,000 less debt.

NewFNP imagines that the phrase "seven-year itch" will take on a whole new meaning.

NewFNP has a few more pearls she brought home that she thought she would share with her NP colleagues and students. They pertain to neurology.

NewFNP was recently visiting BostonFNP who noted that if a patient can climb up onto the exam table, half of her neuro exam was done. An exaggeration, sure, but it makes a point: a busy clinician needs a high yield and fast exam. So, here you go.

Regarding Mental Status -- The MMSE tests the hippocampus only. In a screening test, if the patient can give a 100% coherent history, the mental status exam is likely normal. One must test fluency, comprehension and repetition to determine if language is intact.

Regarding Cranial Nerves -- The cute and funny neurologist at the CME extravaganza notes that visual field testing is extremely informative and underutilized by generalists. In patients who are unable to cooperate, the examiner may point one finger towards the eye of the patient. This should elicit a blink in both eyes and can be recorded as blinking or not blinking to threat.

Regarding Upper Motor Neuron/Pyramidal Weakness -- Assess for pronator drift as the supinator muscle is an extensor muscle which are weaker than flexor muscles. Assess fine finger movements and toe tapping. Is one side faster than the other? If so, problem. Assess one muscle in each of the four extremities. Position the patient in the desired position and tell them, "Don't let me push you down." Test the fingers and big toes bilaterally and you're set.

Regarding Sensory Testing -- Pick either vibration or position sense and temperature or pinprick and test each big toe. Done. Because if your patient is losing sensation, it's starting distally. If the exam is positive, you can move it on up. You can trace a pin up a patient's abdomen and ask him if there is a spot where the sensation changes. If so, map it out with your dermatomes and you'll know where the spinal lesion is.

Ankle clonus indicates a severe upper motor neuron lesion.

To distinguish between true and psychogenic weakness, have the patient bend their arm and you move it down. If a patient is truly weak, the examiner should be able to overcome the patient smoothly. If it's psychogenic or weakness from fatigue, you will note breakaway weakness -- the patient resists at first and the movement is jerky and then the patient no longer resists and the movement is smooth.

The Romberg is a hell of a good test. All you have to do is ask a patient to stand, put their feet together and close their eyes. If they can't stand, you know that their vestibular and/or motor system is jacked. If they can't put their feet together, their cerebellum is effed up. If they fall when they close their eyes, their proprioception is on the fritz and you have a positive Romberg.

And finally, BostonFNP was right -- the single most useful neuro exam is ambulation. Have the patient walk, turn and walk again. Have them walk on their tippy-toes and have them tandem walk.

NewFNP cannot believe that she is back in her urban abode and having to work a real day tomorrow. Thank goodness Gap of all places had some new flattering trousers and a cute stripy boatneck top to ease newFNP back into her work week.

Continuing edu-vacation v.2010 part 2

NewFNP would be absolutely fine to stay on CME, take hikes through beautiful mountain trails, reconnect with good pals from grad school, drink White Russians and play Quiddler.

For those who are interested, newFNP posted her notes from a very helpful EKG interpretation lecture on the newFNP Facebook page. The response has been quick and somewhat shocking. How is it that so many new nurse practitioners feel like their EKG education was utter shit? NewFNP certainly did. One reason might be that the lecture newFNP attended was one that is normally given to medical residents. What the fuck, expensive brand-name nurse practitioner school from which newFNP is a proud alum? Your students don't deserve as good an education? Lame. Apparently, there is a nationwhide epidemic of poorly taught EKG interpretation in NP schools. Super lame.

NewFNP maintains that NP education needs a bit of a re-vamp. A little more specialty exposure that is highly relevant to primary care -- like dermatology, neurology, endocrinology and cardiology -- is in order. Seriously, when so many NPs are planning to work in community health where access to specialty care is nearly non-existent, throw your students (and their future patients) a bone. And then give NPs a residency. It doesn't have to be three years, but even a year or eighteen months would go a long way in helping newly minted NPs be more ready to care for patients.

Sadly, it's unlikely that newFNP will ever be in a position to transform nursing education. Yet with all the NPs in this country and in school currently, she wonders just how in the hell is it that it hasn't been done yet?

Continuing edu-vacation v.2010 part 1

NewFNP is so excited to be away from clinic for a week. Why is taking care of people so exhausting? (And rewarding, of course, but still exhausting!)

In the last week, the clinic was absolutely overloaded with patients, both in volume and acuity. A chief complaint of lab results twice revealed patients with GFRs in the teens. A chief complaint of staple removal revealed a young woman needing the staples removed from the incision in her wrist where she had tried to kill herself. Three likely cancers. One repeat teen pregnancy.

NewFNP is now lounging poolside, beverage at hand, chic new Pixie hairdo getting lots of compliments. She is at CME and she is recharging her batteries. She is somewhat concerned that her batteries need recharging after a mere four months back in full-time community health practice. She does, however, know that one thing that will always recharge newFNP's batteries, aside from J. Crew cashmere and coddington platform suede heels, is a (possibly) inadvertently hilarious comment at CME.

In discussing the newest ACOG pap screening guidelines, an OB/GYN and head of newFNP's state family planning program mentioned that one need never perform pap screening in a woman with a vaginal cuff after complete hysterectomy for non-malignant concerns. He then noted, "This one has been slow to penetrate into clinical practice."

Really? Really? Slow to penetrate, huh? As BostonFNP's dad once said, learning without laughter is like a day without sunshine. NewFNP's day was full of sunshine with that one.

Bring on the double entendres, the dorky medical jokes, and the alcoholic beverages. Because newFNP is on edu-vacation!

NewFNP, that's who.

NewFNP has long been fascinated by two behaviors she often notes as regular occurrences in her clinic.

The first is that patients feel absolutely empowered to walk into the patient care area and ask the medical providers any number of questions while the provider is in between patients. These are patients who may have just happened to drop by, or who received a letter stating their labs were abnormal or who wanted to show a provider a rash or insect bite or what have you.

NewFNP finds this frustrating and fascinating. She would be hard pressed to stop her doctor in the hallway to ask her a question or show her a derm lesion. For being disempowered in many ways, it is remarkable - albeit somewhat misguided - that her patients have found a voice in this way.

The second behavior is fighting and swearing and name calling in clinic.

It was full-on baby daddy drama in clinic today as prenatal patient A and prenatal patient B realized in the reasonably tranquil waiting area that they were both carrying fetuses fathered by the same man. Although it did not come to fisticuffs, clinic security was on heightened alert.

As newFNP's medical assistant was vitaling prenatal patient B, newFNP heard the word "bitch" resonate down the hall four times. At this point, newFNP said, "Uh-uh. Not on my watch." She entered the vital sign area, closed the door and told the patient that while she understood that she was frustrated, that language was not tolerable in clinic.

To which prenatal patient B replied, "Who the fuck are you?!!?"

Indeed.

Fortunately, the remainder of the appointment went much more smoothly and newFNP noted that, in addition to sharing a baby daddy, newFNP's prenatal patients shared the exact same tattoo in front of their right ears on their cheek.

The remaining lot of tattoos - neck, chest and hands included - were all different.

The Freshmaker

To many of newFNP's patients, the human body is a big mystery. Perhaps because her patients have had limited access to medical care, they have fashioned DIY treatments for various ailments. Rubbing alcohol, of course, is the big savior, dematologically speaking. It's got a "cure for what ails ya" mystique amongst newFNP's patients. Tincture of violet is another go-to topical.

But mere derm problems are not the only health concerns for which patients fashion their own treatments.

Throw menopause into the body mystery equation and it's like one big clusterfuck of a mystery to many of newFNP's patients. The uncomfortably itchy atrophic vag, the non-existent sex drive, the beard, the emotional upheaval. Honestly, newFNP isn't looking so forward to it. But she will have options when she gets there. Maybe she'll hook up with Suzanne Somers a la Samantha from SATC, maybe she'll do acupuncture -- who knows!

But what she most certainly will not do it dutifully apply Vicks Vapo-Rub to her atrophic downstairs in other to refresh herself, which is precisely what her patient told her she was doing. Granted, new FNP is nowhere near her menopause (knock wood), but there are a few places in which newFNP would not apply Vicks no matter what and her Lady Gaga is one of them. Talk about a bad romance!

NewFNP Film Festival

Just last week, newFNP was lamenting her Groundhog Day-like hum-drum clinical existence. A pap here, a diabetic med refill there. Nothing but the same old, same old. In fact, she thought that should an abscess walk in the door, she would not have the slightest recollection as to how to treat it.

Well, the universe listened. She had one of those Field of Dreams type of scenarios. All she had to do was imagine an abscess and voila!! Not one, not two, not three but high five abscesses walked into the clinic. On the same woman.

Now, newFNP loves her some Hot Tub Time Machine, but she is remarkably less enamored with Hot Tub Folliculitis. It is not a sequel one would recommend. Apparently, this woman and her paramour took a romantic getaway to a local hotel and enjoyed a soak in the hotel jacuzzi. A fun time was had by all until newFNP's patient began experiencing some angry booty blemishes. By the time newFNP saw her, two of the five abscesses were ready to go.

It was the first time newFNP had ever incised and drained two abscesses on the same patient on the same day and the first time she had ever seen so much necrotic detritus exit the newly opened wound.

As is generally the case with incision and drainage, newFNP's patient felt immediately improved and newFNP felt a renewed enthusiasm for her role in clinic.

And just like in the movies, newFNP (and her patient) experienced a happy ending.

Punxsutawney newFNP

It has been just like Groundhog Day for newFNP. Stepping in the same puddle, getting annoyed by the same people and generally reliving the same thing day after day after day.

And then there was today, when newFNP literally hit her head against the wall while discussing yet another undesired change in her schedule.

Work. WTF. As newFNP's mom used to say, too bad we weren't born rich instead of so good looking.

When it's good to be newFNP

NewFNP has had a wonderfully and oddly rewarding work week.

First, she received the most heartfelt thank you letter from a patient on Monday. She has truly never received anything like it in her life and she knows that such notes will be few and far between in her career.

Then, Dr. Dual-Ivy-League-Degrees told newFNP that "a friend" had stopped by to say hello. Not having many friends in her area of clinical practice, her face must have betrayed her puzzlement. As it turns out, an adolescent patient for whom newFNP cared a couple of years ago (see Healing) just stopped by to say hi and tell newFNP how he was doing. He gave newFNP an awkward fourteen-year old boy hug and updated her on his life. He looked happy and it made newFNP immensely happy to see him feeling good.

And finally, newFNP completed a well-child visit on a 9-month old for whom she has cared since birth. NewFNP also did her mom's prenatal care and cared for her for three years prior to her pregnancy. It is truly one of the joys of family practice to share patients' lives with them and as newFNP held this beautiful baby girl in her arms, she was reminded her of that.

And it's a holiday weekend. Time for a weekend getaway, SATC2 and maybe even a new tattoo!

Ninety-nine

If newFNP could stress one thing -- aside from the importance of clear skin and a cute wardrobe -- to students, it would be that one must learn to elicit and write down a decent medical history. It is very clinically challenging to have too little information and may go as far as to cause newFNP to call chronically poor documenters 'douchebags.'

Say for instance one orders a CEA on a patient for apparently no reason whatsoever, as the subjective area of the progress note is left blank, and then say for instance that CEA comes back mildly elevated (4.2 ng/mL in a non-smoker) with all fecal occult blood tests negative. This may cause newFNP to think to herself, "What the fuck, douchebag."

It's not because newFNP doesn't appreciate that this abnormal test result necessitates follow up. It is that newFNP does not have one iota of medical history from whence to begin.

NewFNP walked into the exam room and immediately made the very subjective assessment that this 70-year old gentleman looked bad. He complained of chronic cough and dyspnea on exertion. NewFNP inquired as to whether he had ever noted hemoptysis with cough. He had. NewFNP was thankful that his daughter attended the visit with him as she mentioned in an off-the-cuff fashion that he had had multiple positive PPDs, but not even one chest x-ray.

Balls.

NewFNP listened to his lungs. The left lung was peachy. The right, not so much. NewFNP started at the bottom: diminished. She moved to the middle: unimpressive. She progressed upward: rales. She moved her stethoscope back down and asked the man to say "ninety-nine." Again the sound was diminished at the bottom of the lower lobe. She moved it to the middle of his back and almost had her tympanic membranes ruptured by the volume with which the words "ninety-nine" resonated through her stethoscope.

Positive whispered pectoriloquy, hemoptysis, positive PPDs sans CXR evaluation and an elevated CEA equals a trip on into the county emergency department. Truth be told, the first three would have prompted newFNP to refer for an ED evaluation, but newFNP is certain that this man received his chest CT much more easily having shown documentation of the elevated CEA.

NewFNP called the patient today. He was hospitalized overnight and had a negative chest CT. The AFB is pending.

And newFNP's documentation is clear, written in neat penmanship and thorough for the next provider.

News Flash

NewFNP hasn't read the study herself, but as she was driving home today she heard a news story on NPR stating that use of Viagra may be associated with long-term hearing loss, as opposed to the sudden hearing loss that was previously known.

This news is revolutionary -- Pfizer can seek a whole new indication for Viagra's use. Gents can continue to bone up on their partners without having to listen to requests to take out the recycling or trim the bushes.

It's the perfect lifestyle medication for the AARP set.

Psych!

NewFNP sees a lot of mental illness in her practice, but it is mostly dysthymia and depression. There have been a couple of wildly positive Mood Disorder Questionnaires, of course, which are generally accompanied by such wild extremes of dress that conducting the MDQ seems almost superfluous.

But it is really rare for newFNP to see schizophrenia in her clinic and it is really, really rare for her to have two schizophrenic patients on the same day.

NewFNP's first schizophrenic patient of the day was a G15P9 three-hundred pound crack-smoking schizophrenic with no teeth who lived in a board and care. She needed a pap and an HIV test which, you gotta hand it to her, is pretty decent self care for someone who is really deeply troubled. She had been off of her Seroquel for a few months and her flat affect was remarkable. NewFNP has never had so many monosyllabic responses to questions, even on her worst of dates. But it wasn't her negative symptoms that had newFNP concerned. NewFNP asked her of she had been hearing things that others could not hear.

"No," she responded.

NewFNP then asked if she had been seeing things that others could not see.

In the flattest of voices, with no change in tone whatsoever, she replied, "Last week the shadows came back."

The way in which she replied was so freaky and the response itself so fucking creepy that newFNP just resumed her Seroquel rather than having her wait for her psychiatric appointment.

Later in the same day, everyone's favorite schizophrenic patient, Cocoa Brown, came back to clinic for a follow up appointment. She, too, was smoking crack, had horrible dentition and approaching three-hundred pounds. Her weight had increased 24 pounds over the past month. She felt uncomfortable and wanted pain medication.

"Can't you give me some Tylenol #3s?" she asked newFNP.

"No."

"Some #4s??" she tried.

"No."

Her lower extremities were edematous. She was experiencing orthopnea. NewFNP's heart sank as she told Cocoa Brown that she was concerned about heart failure. She wrote some prescriptions and, not wanting her to go AWOL as she is wont to do, exited the exam room with her to accompany her to the lab.

As she walked out the room, newFNP's colleague - a good-looking Cuban doctor - told her hello. She smiled, giggled and said in an unreasonably loud voice, "He's handsome!"

NewFNP dropped her off at the lab where she, of course, bolted without having her BNP drawn. Oh, Cocoa. Seroquel or no, newFNP just can't give you the help you need to make you well.

Booze Clues

About a month ago, newFNP was lamenting the effects of hitting the bottle a bit too much. She had sent a gentleman to the emergency room, only to have him return - angry - with absolutely nothing done about his ascites. NewFNP has won him back over, has increased his Lasix and has serially monitored his bilirubin, albumin and weight. She gave him prenatal vitamins as that is the only type of vitamin available in her clinic. She gave him protein and salt guidelines.

She hasn't seen much improvement.

The good news is that the bilirubin is approaching normal and he is abstaining from alcohol.

The bad news is that one might mistake the rotund abdomen under his t-shirt as a basketball but it is, in fact, ascites. It is no exaggeration to say that his panza is 40-week-gestation-sized large, taut and in need of a paracentesis. Now, in addition, the cirrhosis, portal hypertension and ascites are leading to hepatic hydrothorax -- his lungs are wet and he has orthopnea. He has decreased one lousy pound since starting high dose Lasix. He smells like an ammonia factory.

NewFNP is far from being a liver specialist, but she thinks that the situation is not good. He needs a new liver and, even more so than the perfect flattering trouser, they are not so easy to come by.

And he still doesn't have insurance.

Bad Mojo

NewFNP has had one hell of a week and, if she is not mistaken, it is merely Wednesday.

Not that newFNP is overly superstitious, but she finds that the first patient of the day can sometimes set the tone for the rest of the day. And are stars aligned - or misaligned or crossed or something - because newFNP's first patients have been outliers, each and every one of them.

Monday's first patient was a run of the mill IUD insertion and things were sailing along as smoothly as ever. The tenaculum was at 10-&-2 and the Mirena's arms were released when the speculum went AWOL. It settled on the still intact tenaculum while newFNP's MA nearly infarcted. NewFNP should damned well know better but this tends to happen with overweight ladies and this patient was only slightly overweight. NewFNP removed the IUD and blindly attempted to remove the engaged tenaculum. If you have never tried this before, it's a task not as easily completed as one might like. Fortunately, the repeat placement went much more smoothly than the initial in no small part thanks to newFNP's MA keeping the speculum in its desired location.

At least Monday's patient was in the clinic when the situation went down. It is important to have a little background on newFNP prior to hearing about Tuesday. NewFNP is chronically early and is therefore in clinic thirty minutes prior to any other provider. So when a patient who had been standing outside waiting to be seen began seizing in line, newFNP was the only provider on the scene. The ambulance and firetruck had come and gone before the clinic was actually even open for business. And thirty-one patients later, newFNP went home.

And finally, this morning our clinic nurse brought a slurring patient to newFNP's attention. According to the patient, her methadone dose was increased yesterday. It took longer than necessary to elicit this information as the patient was nodding off during the subjective component of the interaction. She denied all drug use which may be the case but people may overdose on methadone and a good place to OD is in the hospital where there are doses of Narcan and ER physicians and IVs. Furthermore, her asthma was uncontrolled. Further-furthermore, she was six months pregnant. NewFNP put her on oxygen and a nebulizer and again invited the paramedics to the clinic.

Please. Please. Tomorrow. Let tomorrow be easy. Super frigging easy.

Hells Bells

For the first time ever, newFNP was jealous of a patient's t-shirt today. This is not to say that she wasn't impressed by the "other bitches just front" t-shirt of some time ago, but newFNP -- ballsy as she is -- just does not have the sack to wear that t-shirt in public. Would they even let her in J. Crew?? Maybe in Barneys Co-op, but probably not J. Crew.

Today, however, newFNP was ready to trade her J. Crew bedazzled tee for her patient's tee. From under her patient's coat, newFNP could see, in metallic silver glory, a C, a lightning bolt and a D and she knew, oh how she knew, that her 50-something year old African American lady patient was wearing a mother-effing AC/DC t-shirt. For those about to rock an AC/DC t-shirt, newFNP salutes you.

NewFNP loves AC/DC.

Her patient's hemoglobin A1c of 10.6%, she loves somewhat less.

There's an app for that

NewFNP dodged a bullet today. Not literally, but technologically.

Outside the exam rooms, newFNP's clinic has lovely fold-down desks. In her fold down desk, newFNP has lab slips, routing slips, medication order forms and, frequently, her iPhone 3GS.

Today, newFNP looked in her desk and her beloved iPhone had disappeared. "Mother fuck," she thought, "Somebody stole my phone." She looked in the providers office and was denied. She looked again in her fold down desk and was again denied. It was at this point that she truly began to lose her shit.

She thought about why in the world she would return to a place where people are stealing phones. She realizes that poverty leads to desperate acts - such as her patient who presented to the emergency room with abdominal pain and cholelithiasis using a fake name in order to avoid receiving a bill she could not afford. NewFNP does understand that these acts are of desperation, of not seeing any other way.

Nonetheless, they are wrong.

NewFNP is not insensitive to the fact that many bankruptcies are results of medical debt. But she does not condone what is essentially stealing health care from the emergency room. The medical system is broken. But when one lies in order to receive services, then is that person a part of the problem? Or are they just making the best of a fucked up system?

Today in clinic, newFNP's colleague blew up her cell time and time again. Given that it was password protected and that the mute function is not immediately accessible if one is unfamiliar with the phone, the culprit had to ditch newFNP's phone in the baby scale. She then walked around the clinic and went to her mental health appointment.

NewFNP had started her on Paxil yesterday and made a referral to mental health -- today's appointment. She had stolen another employee's phone several days before. No one has confronted her. The current plan is to have her escorted to every aspect of her clinical appointments, but apparently to never acknowledge her sticky fingers. NewFNP's clinic manager specifically asked newFNP not to confront her.

Fine. NewFNP will keep her mouth shut. She does, after all, have her phone back. And she learned a valuable lesson: keep your shit with you, newFNP!!

But newFNP is pretty damned certain that she does not want to give her time, service and care to this woman in the future. This patient does not get to have the special newFNP touch. She spent a shitload of time (read: 20 minutes) supportively encouraging this patient yesterday. She does not want to give that of herself to someone who takes and takes and takes, then takes some more.

As an aside, this incident has caused newFNP to re-evaluate her aversion to the lab coat. Perhaps it's time to pick it up off the floor of the coat closet and bring it back to clinic.

Blame it on the a-a-a-a-a-alcohol

NewFNP is no teetotaler. Hells to the bells no. But she does generally drink in moderation. Sure, she might have tied one on at the Liberty Hotel one night and fallen asleep while sitting on BostonCNM's couch while holding a glass of water, only to awake some time later -- cold, confused, wet and holding an empty glass. But those occasions are few and far between.

But newFNP, thankfully, has no addictions. Two of her patients this week have been debilitated by their alcoholism. One man, newly sober, came to newFNP in follow up after having received furosemide for his bilateral pitting edema. Rather than having diuresed some of the fluid, he had gained three pounds in two days. His legs were swollen. His abdomen was taut and distended with ascites. His sclera were yellow. He felt itchy. His bilirubin was 9 point mother-effing 9. He was urinating once daily -- on Lasix! NewFNP sent him to the emergency room. But his liver is shot. And whatever happens in the emergency room won't fix the damage that decades of alcoholism has wrought.

Another patient, a man just a few years younger than newFNP, stated that he drinks at least 100 ounces of alcohol every day and has done so for the past two years. CAGE questionnaire positive 4/4. Replacing meals with alcohol. So depressed that he couldn't imagine going through life any other way. Uninsured.

A pretty decent resource in such a situation is the SAMHSA treatment locator. NewFNP printed out a list of medical detoxes for him, drew some labs, started Paxil and gave him vitamins. She called him today to see if he had had any luck getting a detox bed.

His number was disconnected.

She's ba-aaack!

NewFNP has four words for you people: Hot Tub Time Machine.

Even without memories of movie hilarity, newFNP is pretty stoked to be back in full-time practice. Sure, she cried at work out of frustration yesterday but, to be fair, her dog was under the weather and newFNP was worried about him. (He's fine today.) And yes, newFNP has been inundated with penile warts and emergencies and non-compliant prenatal patients.

But she is certain that she is where she is supposed to be. She is truly happy to just be back in the clinical mayhem, taking care of patients. And there is really something to be said for coming home when it's still light out, hanging out with your pals, walking the dog and watching DVR'd Daily Shows.

Back to square one

NewFNP just returned home from her going away party held at the home of the medical director of the research clinic. She doesn't regret her decision to leave at all, but it sure as hell isn't easy.

Her last day was yesterday. Two weeks ago, she told a 29-year old guy that he was HIV+. She laid the foundation for his continued care, but she would like to have been there to help him. These are the situations that make working in health care so rewarding (helping people in their time of need) and changing positions so sad (leaving people in their time of need).

But on her last day, one of her favorite research participants who finished the trial several weeks ago, returned to the clinic.

"It's your last day, isn't it?" he asked newFNP. He came by to say thank you and to say goodbye. It was really touching.

And so she goes, back to urban community health full-time. Her NHSC loan repayment application is pending and she is happy to have regular hours, busy days and patients to care for.

But tonight, leaving the party, newFNP's heart is heavy. NewFNP loves people easily and there are some people at the research clinic who have won her heart. And she will miss working with them very much.

First time here?

In the shadow of historic health care reform's bill signing, newFNP gently knocked on a patient's door prior to doing her physical exam.

NewFNP does not room her own patients, but she has instructed her MAs to have the patient completely undress, don the paper gown open in front for ease of breast examination and place the paper drape over the lap for maximum modesty protection.

Rarely does the patient take this instruction, passed along by newFNP's MA, to heart.

Most often, the gown is open in the back. No big whoop - newFNP just opens the gown in the front for the breast exam. Sometimes, the patient will undress from the waist down only. Gentlemen will often keep their underpants on while otherwise undressed.

But for the first time, newFNP opened the door to see a 38-year old woman stark naked sitting on the exam table, folded gown and drape sitting untouched beside her. NewFNP reminded her as to how to utilize the paper goods and exited the room.

In what universe do we just hang out nude in the exam room? NewFNP knows that this woman has been introduced to Western medical practice because it was not her first time at newFNP's clinic. So what gives? Are there places in which patients are examined in the buff?

It's also shockingly common for newFNP to enter the exam room for a well woman exam and see the patient supine on the exam table, as though newFNP wasn't going to talk to her at all prior to assessing for cervical motion tenderness or discharge. It's not a stretch for newFNP to imagine that in other countries, where paternalism is a more welcome value in medicine or where there is a large uneducated, illiterate population, providers really do just do the exam and move on.

But newFNP really would like to have some type of therapeutic partnership with her patients and would hope that she could give them some health tools to take home. Therefore, it's pretty helpful for newFNP to chat them up while A) clothed, albeit in paper and B) in a seated position rather than in the relatively powerless supine or lithotomy positions!

Honesty - the best policy?

NewFNP had a bullcrap day at clinic. Sometimes that happens - no big whoop.

But then sometimes a patient says something that just sends newFNP into a personal tailspin.

NewFNP has cared for this patient for years. She's anxious and depressed, but kind. She's very thin and forever trying to gain weight. NewFNP, on the other hand, has the metabolism of a stoned hypothyroid tree sloth. Thus, the only amount of exercise and diet that allows her to be truly thin is an amount unattainable when working full time, visiting her elderly grandma, walking her dog, shopping and doing all the other activities that make newFNP newFNP. And because newFNP is a thirty-something year old white girl who has been conscious of her weight since the days of Seventeen magazine and Forenza, her issue with her weight is both omnipresent and frustrating.

So when her well-meaning patient told newFNP that she was "mas gordita," newFNP wanted to cry in the room. She felt as though she had been punched in her doughy lady belly.

NewFNP supposes that perhaps it's good that her patients feel so comfy cozy with her as to comment on her habitus. But damn if it doesn't feel badly to have her major issue voiced in an exam room. It feels more than badly - it pretty much ruined her GD day. Maybe newFNP should go on Kirstie Alley's TV show with her, sans the Scientology of course.

For crap's sake, her own PMD didn't even call newFNP chubby.

Balls.

Stirrup fail

It is preferable that when new patients come to the clinic, newFNP is (A) on time, (B) fashionable and (C) attentive. Thanks to her super cute new not-even-on-the-website-yet JCrew top, she was quite fashionable. Thanks to her caring nature, she was attentive. On time, however, remains an elusive trait for newFNP in her professional life -- ironic in that newFNP is pathologically early in every other aspect of her life.

So, all in all, two outta three. NewFNP will take it.

The appointment was moving along as smoothly as a newly threaded brow when newFNP attempted to extract the stirrup from its in the table hiding place. The stirrup gave newFNP a little resistance. Not to be deterred, newFNP gave it a little tug. Nothing. Determined to get the best of the stirrup, newFNP pulled at it with a little force.

And that is when the entire fucking stirrup came out of the table and into newFNP's hand. Imagine her surprise! She felt somewhat like the Statue of Liberty carrying her torch as she walked around the clinic, folded stirrup in hand, attempting to find her MA both to share with her the craziness of our clinic environment and to have her help newFNP replace the errant stirrup. Give newFNP your tired, your poor, huddled masses yearning to breathe free -- and to have their pap tests with intact examination tables.

NewFNP not so gently maneuvered the stirrup back into place and with the snap of broken plastic, shifted the stirrup, and subsequently the patient, into position and continued on with the exam.

Bienvenidos a nuestra clinica de la comunidad!, newFNP told her patient, who was kind enough to laugh.

It's not you, it's newFNP

NewFNP needs her head examined.

She gave notice at her research position and is going back to full-time community health. It's not as crazy as it sounds, she supposes. NewFNP has been spending a lot of time lately thinking about what kind of FNP she wants to be. (This is certainly something that her name brand nursing school did not teach.) High atop that list is that newFNP wants to be a community health practitioner. There certainly is a pride one feels when working in and for an underserved community.

NewFNP also wants to be a good teacher, a supportive listener, a knowledgeable medical practitioner, the type of person who says yes more often than she has in the past. This may be far more than newFNP can realistically achieve, but it is important to articulate and strive towards one's goals.

As such, starting early April, newFNP will be back in the thick of it. She hopes that she won't burn out so quickly this time around and that she'll have a lot of interesting tales to share.

That being said, she will miss working for her brilliant and hilarious research physician and her talented and creative research assistant. It is so hard to let people down.

Soda - two thumbs down

NewFNP was at the gym yesterday, reading the NYT whilst stationery biking. It's not her favorite workout, but yesterday was a day during which newFNP had to kill two birds with one stone. Thus, NYT and exercise together -- it's like church for newFNP.

The Week in Review section had a below-the-fold article about taxing soda written by Mark Bittman, whose bread recipes tend to be quite good, but whose sugar cookie recipe leaves something to be desired. Clearly, no manufacturer of any product is supportive of a tax on their wares, especially to the tune of 1 cent per ounce and when your product is being blamed as a component (and not an insignificant one) of the obesity epidemic. The industry quotes against such a tax were so transparently douchey, especially the one from one Mr. Derek Yach of PepsiCo who wondered if a tax on sugary food might make things worse by leading to an increased consumption of fat.

It should come as no surprise that newFNP supports such a tax. (She supports taxes on cigarettes as well. If marijuana were to become legalized, she would support a weed tax.) Soda has no nutritional benefits. Okay, okay, it has sugar. But overall, while tasting good, it is a piece of dump nutritionally speaking. When newFNP counsels newly diagnosed diabetics - something she does with alarming frequency - one of the first points she makes is that soda is a no-go, a killer, absolutely a never on the diabetic food pyramid. She believes that using the public health model that targeted cigarette consumption is a reasonable approach. After all, cigarette consumption has decreased significantly over the past few decades.

The article got newFNP thinking that there are other ways to decrease soda consumption. In newFNP's clinic, many, many of her patients receive food stamps. A quick trip to the national food stamp program website states quite clearly that the goal of the program is to help low-income families buy food that supports good health. Clearly, soda should not be on that list. Food stamps are a government program and the government already dictates some exclusions from the food eligibility list. For instance, alcohol is excluded, yet non-alcoholic mixers are not. Cigarettes are excluded. Flaxseed oil is excluded, yet cooking wine is okay. Hell, you can get bows and arrows with food stamps if you are lucky enough to live in Alaska!

If newFNP were asked to update the eligibility list, she would exclude all non-dairy sugary beverages. Good-bye Sunny D! You're not fooling anyone! See you later Orange Crush, you asshole. No one needs you! And no one would be about to do the Dew with food stamps.

But newFNP wouldn't stop there. No Hot Cheetos or any kind of chips. Knowing that food stamps and health are political issues, she might compromise and let Sun Chips or Baked Lays sneak by. No candy. No sugary cereals. No Lunchables. No Hostess, not even the delicious chocolate doughnuts that are so yummy on roadtrips home from snowboarding.

Yes, nutritious foods are expensive. Fresh fruits and veggies go bad if not eaten in a timely fashion. But frozen veggies don't. And if one's cart isn't piled high with a bunch of shit, the food stamps might go a little farther and actually work toward the program's goal of supporting healthy nutrition options in poor families.

And then move on to the schools. No soda dispensers and quit cutting recess and P.E. time. Seriously people - don't just have kids run the mile. Throw a kid a bone and help them to find a physical activity that they like, that they'll do for their entire lives. How about mat pilates P.E.? Hip hop dance P.E. class? Weight training. Not square dancing. Repeat - not square dancing.

Michelle Obama, if you're reading this, newFNP is here to help.

It's all about the Hamiltons, baby!

NewFNP realized that she censors herself and that is so weak. So fuck it, let's talk about poverty.

It feels a little like a Seinfeld episode to say "not that there's anything wrong with it," but perhaps it is not entirely transparent that newFNP thinks that there is nothing wrong with being poor. That being said, there is also nothing wrong with wanting to not be poor either.

Poverty sucks. Urban poverty super sucks. Almost five years into practice, newFNP continues to be struck by the difficulties experienced by her patients -- difficulties truly unknown to her. Urban poverty often means gangs, school failure, cockroaches in ears, overcrowding, poor nutrition, medical debt, precarious housing, stress.

NewFNP grew up kinda poor after her parents divorced. Her dad often didn't pay the $400 child support payment that was to be shared between newFNP and broFNP. The first duplex in which we lived post-divorce was in the shadow of the interstate. But newFNP's mom had a college education and newFNP very frequently heard the mantra of the importance of a college education. And this was when she was in third grade. So while newFNP's family was financially poor, she had some socioeconomic buffer based on her mom's education.

NewFNP's patients, by and large, have no such buffer. They often live day to day, hand to mouth. Daily life beats them down enough that there is very little future orientation.

A patient today, a 30-year old unemployed woman with three children, eight year-old rippled breast implants and a tubal ligation, was interested in A) reversing her tubal in order to have another child with her boyfriend of four months and B) getting a do-over on the implants. Yes, get those rippled things switched out before something bad happens, absolutely. Yes, your health is worth the $5000 or whatever the new boobs cost. Reversal of tubal ligation? Likely very expensive and likely not covered by one's state-funded insurance program.

But are these out of pocket expenses financial priorities? Does she have Suze Orman approved savings? Do her children have college savings funds? Is it a universal truth that all parents want their children to succeed and be financially stable?? Does newFNP have any fucking business in encouraging her patients to think about such things or even thinking these thoughts in the context of patient care?

NewFNP doesn't know, nor is she any kind of sage financial guide. Lord know that if newFNP had an extra three grand laying around, she would have a Bertoia Bird Chair faster than you can say sham-wow!

But newFNP's gut says that even the least educated, financially marginalized champurrado vendor would prefer that her child be a teacher than sell shoes on a corner. But how does she help her child get there if she herself has no idea, if she's illiterate, if she hasn't set foot in a classroom since the 7th grade?

Or what is a family teaching their children if the parents don't work, if they hang out and watch TV and have state aid? Like, if the goal is state aid, end of story? If there are four fathers of four children?

(Is newFNP completely losing her liberal credibility for even thinking such things??)

There is definitely an argument that goes like this: NewFNP, just shut the hell up and see your patients for their ear infections, et cetera et cetera.

Then there is the argument that goes like this: People need help and they often come to clinic for more than just what their chief complaints might have one believe. And people who impact the lives of others do more than the bare G.D. minimum.

Perhaps she should adopt the former approach when she notes feelings of judgment towards a patient, as she did with the BTL-reversal wannabe today. Providing good medical care is, after all, a good outcome in and of itself.

But helping to teach someone avenues through which to escape poverty - that seems like an okay thing to do as well. Is that just too pie in the sky? Is it classist? Is it even a realistic goal given the constraints of clinic? Ah, fuck it. Who knows.

Yippy-kay-yay!

NewFNP's mom died twenty-two years ago today so after a busy day at clinic, newFNP was feeling a little gloomy on the quiet ride home.

Then she saw a gentleman riding a horse down the sidewalk along a very busy thoroughfare in her very urban city and broke into laughter. He was heading west, then turned to head north down another busy street. Adios, partner.

Who wouldn't feel better?

Potty mouth

NewFNP had a completely fucking bizarro day at clinic today.

For starters, her first two patients -- both new to clinic, of course -- had schizophrenia. The second one also had a wonky eye.

Then there was the chlamydia patient -- the first chlamydia of the day. The first patient was pretty normal. However, he had genital warts that were growing in perfect projectile symmetry on either side of the glans, conjuring images of a caterpillar. NewFNP is a sucker for symmetry and, in fact, has a real aesthetic bias against asymmetry and has, frankly, never seen warts grow in such mirror images of each other in non-touching skin.

Then she had a syphilis patient and began to wonder if she had stumbled into the mental health/STD clinic.

Then she saw what felt like another 7 million patients when she came across her second chlamydia patient of the day: a 17-year old primigravida who is 38 weeks and 4 days pregnant and who had her first prenatal visit last week. Can newFNP interest you in Azithromycin?? Open wide.

Then she saw five other patients when her clinic manager and the brand new RN came in at 5:15 and asked if she would please see another patient, to which newFNP replied, "You have got to be fucking kidding me." And then she saw two more patients.

NewFNP's mouth is absolutely going to get her in trouble one day. She needs to reign it in. In her defense, however, newFNP did not have even a 10 minute break today. She peed once and texted a patient her lab results from the bathroom.

What newFNP really needs is to work in a high-functioning community health clinic with the gestalt of a tattoo shop. Barring that, though, she really should learn to just shut the eff up.