What school doesn't teach about being a nurse practitioner

Closing Time

2011-05-06T15:56:00.001-07:00

It's time to go.

NewFNP has really enjoyed this blog over the last almost-six years, but it's time to move on. The blog will stay up and the email address will stay active so if you have a question for newFNP, she will happily respond.

Thank you all for reading and writing. Keep fighting the good fight.

Boola boola motherfuckers!

NewFNP out.

POP!!

2011-04-10T12:12:00.001-07:00

NewFNP has previously discussed the lady scourge of urinary incontinence. Kegels, ladies, kegels!! But what newFNP hasn't talked about is the sister scourge of pelvic organ prolapse.

NewFNP is super content to leave her lady-junk all up in there, where it's supposed to be. Except the parts that are supposed to be outside. They can stay there. NewFNP is just saying this -- a reasonable expectation for aging is to keep all yo junk in its O.G. spot. Let's get Suzanne Somers to work on this one with her team of experts!

Because when innies become outties, that is not so good.

What makes newFNP think of this on a lovely Sunday is a patient who came in with a chief complaint of feeling something falling out of her vagina. This is the second CC of this nature, but as this patient was in her 50's and was not in the post-partum period, newFNP was certain that she would not find any form of placental treasure upon examination.

What newFNP did see was a fairly obvious cystocele-rectocele combination platter. As newFNP's patient had mentioned that the sensation of fullness was more pronounced when she was using force, newFNP went ahead and had her patient give her a little Valsalva while in the lithotomy position.

Had newFNP been wearing 3D glasses, she might have had a heart attack. "Okay, stop!" she told her patient, fearful that she would deliver her uterus into newFNP's hands.

NewFNP quickly completed the OB/GYN referral and was ready to end the visit when her patient asked her, "Is that happening because I'm not having any sexercise?"

"Did you say 'sexercise'?" newFNP replied.

She had indeed.

Not so much a lack of sexercise, no, but her four >8 pound babies delivered vaginally might perhaps be a more likely culprit. (Or, in other cases, family history. Or obesity. Or hysterectomy.)

And swallow

2011-03-26T16:35:00.001-07:00

The Friday before newFNP's grandma died, newFNP was scheduled to see a GI specialist to find out just what in the hell is up with her stupid esophageal pain. Of course, she cancelled that appointment and rescheduled it for yesterday.

NewFNP's handsome, young and friendly gastroenterologist didn't think that newFNP is having diffuse esophageal spasms at all. No, in fact, he thought that she is having eosinophilic esophagitis (EE).

Fucking allergies! This one newFNP blames completely on attending fancy grad school on the opposite coast from whence she hails and where she developed mother-effing food allergies.

Dr. Handsome thoughtfully wrote down a list of foods that commonly trigger EE: corn; gluten; dairy; shellfish; peanuts; and soy. Great. It's like the most anti-patriotic elimination diet ever! No corn? No wheat? No dairy? What's next? No Pledge of Allegiance? And no soy? How is newFNP going to get her salad protein??

Stating that he wasn't entirely certain, Dr. H offered to provide newFNP with an esophagogastroduodenoscopy -- biopsies and all -- to find out just what is the damned problem.

Now, newFNP generally doesn't let a guy put his tube down her throat at their second meeting, but for this guy, newFNP is going to make an exception.

End of an era

2011-02-23T12:16:00.000-08:00

NewFNP said goodbye to her grandma this past Sunday. What a wonderful gift to have had her all these years and to have been able to take care of her in a way that honored her life and the extraordinary role that she played in newFNP's life. NewFNP and her brother were by her grandma's side as she took her final breaths and slipped away.

A very special lady, who taught newFNP the fun of shopping and girl time, who indulged newFNP's love of middle school reading with the entire Sweet Valley High collection, who slaved over newFNP's prom dress with her, who loved newFNP equally during her darkest hours and when she was shining her brightest, she will be missed and she will be treasured.

And she will always, always be loved.

Ho no she didn't

2011-02-03T20:10:00.000-08:00

NewFNP was driving to work early this morning and it's possible that she didn't entirely have her senses about her. She was driving through an area that is known for being up to no good, but that's pretty routine for her so it was no BFD.

Readers of newFNP know that newFNP considers shopping to be as essential to her life as oxygen, George Clooney and the Sunday Styles. So when she saw a sign for "hoe-tique," she did a double take.

Hoe-tique?! Shitty neighborhood or not, it doesn't seem right that one could just walk in and buy a ho like that! Or maybe they just sell ho accessories such as short-shorts and thigh-high patent pleather boots.

Upon closer inspection, newFNP realized that the store was, in fact, a Shoe-tique but that the "S" had faded over time. Now, newFNP does love herself some new shoes, but she was a little happier when the store was the hoe-tique.

After all, new shoes are a dime a dozen. New hos are harder to come by.

Broken safety net

2011-01-23T16:45:00.000-08:00

NewFNP has no problem with HMO's. This is quite likely because newFNP is generally healthy, is in the know, and -- in true newFNP fashion -- has her primary care provider through one of the best medical groups in the nation.

When newFNP went to her PCP and told her that she has been having diffuse esophageal spasms for two years and finally thought it was high time to get that mother-effing upper GI and quite possibly some esophageal Botox, she received her referral before leaving the office and had a specialty appointment twenty minutes later. The system is connected and coordinated.

If, however, you are newFNP's patient and you have a state-insurance funded HMO and you need specialty care, you are jacked.

Take, for instance, newFNP's 31st patient of the day last Thursday. Three months ago, she was told at another clinic that she was HIV-positive. She was told to get HIV care. Where to get that care? Apparently that was not a part of the discussion. Thus, this 32-year old woman showed up at newFNP's clinic stating that she heard we did HIV care.

We do not. Yet.

So newFNP picked up her cell phone, dialed a nearby clinic and handed her phone to the patient who proceeded to make the appointment. Only that clinic doesn't take her HMO.

Son of a bitch.

Yes, newFNP could have gone through the regular old system of giving the referral to the referral coordinator who would get to it as soon as she could given the extraordinary amount of work that she has. Then she would mail the referral to the patient. But the patient wasn't "trying to get no mail from an AIDS doctor" so that option was out. And frankly, this woman had been wandering around for three months out of care and that is just not acceptable to newFNP.

The patient got all of the details regarding the insurance switch she would need to make and then spent some time talking to newFNP about how she doesn't want the HIV meds to make her crave drugs again, about how she can't get state financial aid because she committed a felony while crack addicted and then cried for her diagnosis, for her situation, for her frustrations. NewFNP listened, acknowledged, supported.

She left the room forty minutes later -- five minutes before the clinic was scheduled to close -- and was told by a member of the support staff and HIV planning team, "I thought you were taking care of this!" To which newFNP replied, "What the fuck do you think I'm doing??!" As though taking the time and providing the care to this woman was unacceptable.

NewFNP was livid. And then she went and saw patient number 32.

Bootie-licious

2011-01-17T18:06:00.000-08:00

Some things never change with newFNP. For instance, she will never stop looking for the perfect shoes to wear to clinic that are both stylish and comfy.

She found a near bulls-eye on a recent trip to Dolce Vita with her BFF but remarked that she would not want to wear her perfect suede wedge boots if her had to do an IUD insertion. One drop of betadine and that luscious beige suede would be ruined!! She swore that she would remove her new boots rather than take the chance at their being destroyed. After all, there are no surgical booties to cover newFNP's fashionable booties in her clinic.

So of course she headed to clinic last week with her super cute booties and was greeted with the news that the room was all set up for an IUD insert.

Balls!!

At first, newFNP felt a little awkward at the thought of removing her shoes for a procedure and, of course, she shouldn't take off her shoes at work. It's gross, for one, and her shoes offer her some protection from sharps and fluids and god knows what, for two. But fuck that! These boots are brand new and beige suede.

At first, newFNP followed that path of correctness and safety and kept them on, but tucked them under a drape. But she was nervous and couldn't go through with it.

When her patient was in the lithotomy position, newFNP quietly removed her booties and scooted them out of harm's way. The IUD insertion went smoothly and newFNP replaced her boots once the betadine was out of sight.

Thank goodness newFNP was wearing cute argyle socks that day! She would have hated for her medical assistant to have seen some of her B-list socks!!

Put this baby to bed

2010-12-30T19:33:00.000-08:00

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!

2010-12-20T21:38:00.000-08:00

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

2010-12-13T19:20:00.000-08:00

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!

2010-12-06T20:56:00.001-08:00

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

2010-12-05T19:24:00.000-08:00

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

2010-11-29T21:22:00.000-08:00

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

2010-11-17T21:48:00.000-08:00

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

2010-11-08T21:12:00.001-08:00

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

2010-10-28T18:38:00.000-07:00

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

2010-10-26T18:36:00.000-07:00

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!

2010-10-15T18:21:00.000-07:00

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

2010-09-22T19:10:00.000-07:00

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

2010-09-06T19:48:00.000-07:00

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!

2010-08-29T17:58:00.000-07:00

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?

2010-08-21T19:01:00.000-07:00

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.

2010-08-15T20:57:00.000-07:00

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

2010-08-11T15:42:00.001-07:00

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

2010-08-09T13:00:00.000-07:00

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.

2010-07-13T21:44:00.000-07:00

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

2010-07-02T11:37:00.001-07:00

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

2010-06-21T20:17:00.000-07:00

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

2010-06-16T20:41:00.000-07:00

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

2010-05-27T20:30:00.000-07:00

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

2010-05-25T18:52:00.000-07:00

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

2010-05-19T21:13:00.000-07:00

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!

2010-05-16T16:37:00.001-07:00

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

2010-05-12T18:52:00.000-07:00

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

2010-04-28T21:00:00.000-07:00

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

2010-04-21T19:56:00.000-07:00

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

2010-04-15T21:35:00.000-07:00

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

2010-04-13T20:45:00.000-07:00

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!

2010-04-07T20:03:00.000-07:00

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

2010-04-03T19:53:00.000-07:00

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?

2010-03-24T07:03:00.001-07:00

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?

2010-03-18T22:29:00.000-07:00

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

2010-03-02T19:36:00.000-08:00

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

2010-02-26T14:38:00.001-08:00

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

2010-02-15T12:30:00.000-08:00

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!

2010-02-13T21:07:00.000-08:00

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!

2010-01-28T17:29:00.000-08:00

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

2010-01-26T21:40:00.000-08:00

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.

S-A-TUR-D-A-Y! Clinic!

2010-01-17T08:48:00.000-08:00

When newFNP was in public health school and was discussing access to health services, she recalls evening hours and weekend hours being touted as one option the system provides in order to increase access to care. All these years later, it is exactly those two things that newFNP likes the least about her schedule.

Nonetheless, as she was seeing patients yesterday during a very busy Saturday, she was reminded of a few lessons in patient care.

It is not uncommon that when newFNP asks a patient how they are, they answer "Mal." Bad. Truth be told, it is newFNP's least favorite way to start a visit (although she completely acknowledges that this reaction is completely her own baggage). Can't we just pretty please have a moment of pleasantries before we delve into the nitty-gritty of the visit? Alas, newFNP has found that when people answer in such a way, it generally is because they are doing badly and probably have taxed each and every ounce of their resiliency reserves to the point of complete bankruptcy such that they can't even fake it anymore. It is always a tip off to newFNP that she must screen for depression.

It is also not uncommon that as patients are waiting to be seen at newFNP's clinic, the waiting room is frequently SRO. It is loud. It gets dirty. The temperature is never just right. It sometimes smells not-so-fresh. The time spent in that room can accumulate into hours. Being a competent and kind provider goes a hell of a long way to ameliorate the effects of that hellish wait. As she was finishing up a prenatal visit yesterday -- one which truthfully felt a little rushed to newFNP -- her patient told newFNP, "Can I see you again? I like the way you take care of me." It made newFNP feel proud and guilty at the same time, feeling good that the patient felt well cared for and feeling mal knowing that this patient didn't really receive the best care newFNP could have offered her.

It is really wonderful to take a moment to reflect upon these lessons. And it is so much sweeter as newFNP reflects upon them while in her dining room, drinking French Roast, Sunday NY Times by her side, decidedly out of weekend clinic responsibilities.

Pop

2010-01-14T20:48:00.000-08:00

NewFNP is hard pressed to identify anything that separates her from her patients more than does diet, culturally speaking.

One of newFNP's physical exam preventive health screening questions is: Do you eat fruits and vegetables every day? The answer is generally no. She also asks: Do you drink soda? This answer, in contrast, is generally yes.

But the answer is not so commonly yes to the tune of 60 liters of soda daily. Sixty liters seems, shall we say, excessive. That level of consumption constitutes approximately 2500 calories per day and 100% of them in nutrient-void carbohydrates. In addition, it's doubtful that all remaining calorie source were from broccoli and artichokes.

Her patient very earnestly told newFNP that she was uncomfortable with her weight and wanted to change her diet in order to drop some ell-bee's. Nutritional counseling was not so much of a challenge.

But newFNP wondered what happened to the off switch in someone who consumes that amount of soda. It might meet the DSM-V criteria for soda addiction. It is affecting her health, she continues to use soda despite suffering as a result, she has tried to stop but hasn't been able to yet. NewFNP didn't recommend any specific diet, but she did recommend complete cessation of soda consumption in addition to initiation of physical activity.

Can we incorporate infant and childhood nutrition into prenatal classes? Because this kind of whack diet needs to stop way the hell before it starts!

Undecided

2010-01-06T20:55:00.000-08:00

Oh my God, does newFNP ever need to get her shit together.

For one, she misses clinic. She loves working at the research clinic because she has awesome colleagues. But she loves working at the community health clinic because she loves the work. (And has a handful of awesome colleagues in the midst of the wackiness.)

For two, how do ladies figure out A) if they want to have kids and B) when the hell to interrupt their very busy lives in order to do so? NewFNP is on the fence and she is also AMA. On the one hand, she sees an iPhone pic of BostonFNP holding her newborn and looking happier than quite literally ever before. On the other, she sees a thirty-something year old woman with an eviscerated perineum after a perineal wound repair dehiscence. NewFNP has a longstanding history of not inviting chaos into her personal life, yet completely acknowledges that kids are kind of a cool chaos. If only newFNP could be a dad...

For three, why in the world did newFNP consent to getting her cholesterol checked the Monday following the Christmas/birthday holiday weekend? How could newFNP, who practically survives on veggies, fruits, Omega-3 supplements and grains, have somewhat elevated triglycerides?? She'll tell you - a weekend full of shrimp dip, bagels and lox, mashed potatoes and birthday cake. NewFNP makes it a practice to completely invert her food pyramid December 24-26 and now look where that practice has landed her. Mother fuck. NewFNP hates not getting 100% on her FLP.

So it looks like newFNP has some shit to figure out this year.

Whatever... bring it.

Happy Holidays 2009

2009-12-22T20:38:00.000-08:00

Oh my God, does newFNP ever love the holidays. Know why?

A) Time off.

B) Go shorty, it's newFNP's birthday! Not today, but ’tis the M-F-ing season. For her birthday, newFNP bought herself a cashmere sweater on sale. And an Audi. (Hey, it's diesel and newFNP loves herself some leather seats and dual moonroof.) And she even got a cake and a song at clinic today!

But you know what can put a damper on newFNP's holiday/birthday cheer? A $24,000 medical bill from her grandmother's 24-hour hospitalization. Bear in mind, this does not include one cent of physician services. Those are still to come. Of course, newFNP's sweetheart of a grandma won't have to pay this size XXL bill thanks to Medicare. The Medicare discount is a cool $22,000.

Guess what an EKG ran? $494!! NewFNP did 10 EKGs today and she's pretty sure that her clinic won't be billing any insurance $494 per test performed for the frigging things!

So again, why are we not supporting a public option in healthcare reform? Is there a reason that anyone should receive a $24000+ bill for 24 hours of care? Who in the hell can pay for that?

And if there is someone, is he married?

******

If there was ever a time newFNP wanted a hospital to do its job, it's now. NewFNP is thinking nothing but positive thoughts for Pudge and mature lungs and closed cervices. BostonFNP, keep safe. Love you.

Always have and always will

2009-12-05T17:58:00.001-08:00

NewFNP has the raddest grandparents -- all of them.

When her paternal grandfather died while newFNP was in nursing school 3000 miles away, newFNP asked her brother to help take care of their grandmother. BroFNP moved in and cared for her for four years. When her care exceeded what could be done at home, newFNP moved her grandma to her urban jungle. She had been faring rather well for a 94-year old lady with dementia until this week. She had cough, she was tachypneic, and she had unilateral lower extremity edema. (But she always has edema because she's got the ole Norvasc and she's in a wheelchair.)

Now, newFNP and broFNP have power of attorney, DNR, advance directives -- the whole nine. But having all that is all well & good until one needs to use them.

NewFNP's grandma was admitted to the hospital and had a thoracentesis which drained 700cc of fluid from her right lung. Her duplex ultrasound showed extensive DVTs in her left thigh.

NewFNP opted not to treat. Anticoagulation is not the move for a 94-year old woman and won't improve her quality of life at all. Plus, just last week, her grandma told newFNP that she was "ready to hang it up." NewFNP knew that deciding against treatment could mean deciding for a pulmonary embolism. That's just kind of the beauty and the bitch of being in health care -- one understands the implications of one's decisions. And, frankly, a massive PE is not a bad way to go.

Her decision weighed heavily on her as she watched her grandma doze off in the hospital bed. As she waited for the ambulance to transport her back home, she crawled into her grandma's hospital bed and sobbed. Her grandma reached her hand out to hold newFNP's hand.

"Honey," she said, eyes closed,"I hope you're not getting sick. It sounds like you're stuffed up."

"Yeah Grandma," newFNP replied, "I'm a little stuffy." All the memories of summers and swim lessons and shopping for ESPRIT and lunches at I. Magnin and how her grandma consoled her the evening that her mom died were playing in newFNP's mind as she laid next to her.

NewFNP remained in bed with her Gram sniffling and soaking the sleeve of her James Perse t-shirt until the ambulance arrived. Every once in a while as newFNP and her Grandma snuggled, her Grandma would reach her hand up to scratch her head and then slip it back into newFNP's and give her a little squeeze.

"I love you so much, honey," her grandma told newFNP. "Always have and always will."

When she was leaving, newFNP gave her grandma a kiss goodbye. She turned to get her purse when her grandma said, "I want another kiss."

You got it, Gram. Whatever you want.

Pole Position

2009-12-01T19:59:00.001-08:00

NewFNP really enjoys IUD placements. She finds procedures fun - a little break from the assessment of DP pulses and the futile attempts to palpate hepatosplenomegaly in her generally overweight patient population.

Today, newFNP had a gregarious patient present for an IUD insertion. NewFNP asked her patient if a colleague who is learning how to place IUDs could observe the procedure.

"Yeah, sure," she replied. "I mean, I used to be a stripper so it's all good."

NewFNP replied, "Oh wow - what was that like for you?"

Some people might be amazed to learn that newFNP had never met a stripper before! She wanted to ask her all the details. How does one learn to pole dance? Do pasties hurt upon removal? What was it like?? Hell, newFNP doesn't even like to walk around the Korean day spa naked, but the rub-n-scrub is worth the lady nakedness. Dollar bills in g-strings would not be worth it to newFNP.

Her patient told newFNP that, not unlike health care, the location of the practice played a significant role in how well one was treated. In ghetto areas, her patient explained, her treatment was not so good. But in nice areas - "with lots of white guys" - it was a pretty good gig.

NewFNP didn't go into it any further, but she would actually really like to learn what it was like for her patient. What was it like the first time she performed? Did she feel hesitation about considering exotic dancing as a job? Was it worth it? Did she feel exploited? Alas, it seemed inappropriate to ask such questions while seated at the business end of the lithotomy position looking past the pierced clitoral hood to the perfectly centered cervical os.

It was the most seamless insertion of newFNP's career. Her patient was completely comfortable and pain-free, talking to newFNP and laughing the entire time.

It's quite nice to have appointments like that during a generally hum drum clinic day.

Two things

2009-11-21T17:37:00.000-08:00

One. NewFNP is fucking stoked not to have a mammogram again until age fifty. Not so nuanced a comment, but personal indeed.

Two. NewFNP was leaving Whole Paycheck with bag full of organic goodies and was listening a gentleman on NPR listing the reasons for opposition to health care reform. One reason was the loss of choice. (He didn't specify, but newFNP assumes that he is talking about choice over health care providers as well as the government having a say in what health care can and cannot be provided.) Oh, the irony! After all, isn't there a huge brouhaha over including the choice to have an abortion in the current health care reform debate??!

That kind of stuff makes newFNP want to tell people to suck it.

Choice

2009-11-14T08:24:00.000-08:00

NewFNP doesn't need to be convinced of anyone's reasons for seeking abortion - she has been pro-choice for as long as she knew that the issue existed.

But when newFNP met a young woman in clinic this week, she thought to herself, "Now this is a person who should have an abortion." This young woman is 20-years old. She was pregnant for the ninth time and did not care. According to her, she has had seven miscarriages - some of them provoked but she declined to elaborate further. She is bipolar and unmedicated. She is homeless. The father of this baby is incarcerated. She smokes one pack of cigarettes daily. Until a few weeks ago, she regularly used methamphetamine. She was carrying a prescription for Haldol due to her recent suicide attempt.

The one child who she carried to term is in foster care. She opted for foster care rather than adoption because - in her words - adoptive families get too close to the kid. Yeah, newFNP is pretty sure that that is the point of adoption.

So -- chronically homeless and chronically mentally ill. Polysubstance use. In the best of circumstances, a new baby is challenging. This young woman was not experiencing the best of circumstances.

NewFNP hopes that the foster care system in which her six-month old child is placed finds this baby a loving adoptive family who will raise her with love and assuage the effects of the tumultuous pregnancy and the family history of mental illness and drug addiction.

And she hopes that this mom will terminate this pregnancy and will seek birth control services, mental health services, substance abuse treatment and housing. Maybe one day she will be able to care for herself and a pregnancy. But this is not that day.

And it's not newFNP's choice.

Saved yet again

2009-10-27T22:13:00.001-07:00

Last week, newFNP had had it. She never wanted to return to clinic again. She had one especially bad encounter with a patient that left both parties feeling upset and involved newFNP telling the patient, "Pregnancy is not a disability - you do not need to quit work yet" in a not-so-nice tone and the patient telling newFNP, "You don't understand -- your job is easy." To which, of course, newFNP had an internal fit of apoplexy. It is a damn good thing that newFNP does not know how to say, "You have got to be fucking kidding me" in Spanish.

That, coupled with a few other institutional issues, prompted newFNP to send her resume out early yesterday morning.

And then, newFNP'll be damned, but wouldn't you know it if a patient reached out and touched newFNP in a way that made her love her job all over again. No - in a way that made her want to stay in her job.

This patient is in her 60's, she is a university retiree from newFNP's public health alma mater, she has Crohn's disease, is a breast cancer survivor, fell and had a major knee surgery two months after her chemo ended and was determined to be unable to care for herself post-operatively in her home as she lived alone. Thus, adult protective services placed her in a hella ghetto senior's community a stone's throw from newFNP's clinic which, in case anyone has been sleeping for the past four years, is in one hell of a shithole area. Prior to this determination, she was living in a peaceful suburb in the foothills of newFNP's city. She hasn't had a mammogram in two years and she is only three years post-mastectomy. She hasn't had GI follow-up in over a year. She feels as though she cannot turn to her children for help.

As she recounted her story to newFNP, newFNP just took a moment to acknowledge the hell this woman had been through and asked her if she wanted to talk to a counselor. She made an expression that spoke of her pain, of her sorrow and of her relief in being offered .

She shook her head slowly, ruminatively. "I could use it," she replied, nodding. "It has been a really hard couple of years."

NewFNP put down her pen after having filled the past medical history form and then some on this woman's encounter form, leaned forward toward her patient and said, "I am going to help you." And she meant it -- she meant it more than she usually does. And she felt the importance of helping this woman more than she has in quite some time.

And she did help her. She got her a mammogram even though mammograms are booked through 2010. She got her a counseling appointment. She overstepped her bounds and gave her a friend's email address in the hopes that this friend had some insider knowledge regarding other communities available. She listened. She cared.

But equally as importantly for newFNP is that this woman helped her. She saved newFNP from utter desperation and frustration with her job.

What a wonderful gift newFNP received today. She is so thankful.

One week follow up

2009-10-15T18:39:00.000-07:00

Followers of newFNP may recall that last week she sent a gentleman to the emergency room with a temp of 102.3 and purulent nasal discharge. The day she sent him, he has come to clinic on his bike. When El Conejo was a no-show, newFNP told him that she would get him a cab and that he could lock up his bike at the clinic.

At that time, newFNP had no way of knowing how fortuitous it would be to store his bike for him.

He came today to pick it up, telling newFNP's MA that he was there to pick up his "Mercedes." As newFNP's MA took him to unlock his bike, he told her that the emergency room physicians had drained a lot of pus from his face and told him that if he had waited one more week, he would have lost his eye. He was hospitalized and given IV antibiotics for a week.

He was also diagnosed with leukemia.

Unfortunately, it makes sense. Why would an otherwise healthy 39-year old guy have 6 months of purulent nasal discharge and weight loss? At the time, newFNP was thinking immunocompromise due to HIV. (He had never tested positive, but newFNP was just trying to make sense of the bigger picture.) She had not thought of leukemia when she decided to send him to the ER.

Learning of his diagnosis A) reminded newFNP how crucial it is to consider patients in context and B) made newFNP feel so relieved that she sent him for further evaluation and treatment. Sadly, she knows that in other clinics, he would have received antibiotics and been sent on his way. He's poor, uneducated and uninsured. Maybe he would have gone to the emergency room when his eye was beyond saving. Maybe the infection would have overwhelmed his compromised immune system.

The silver lining is that his purulent nasal drainage is resolved and he has oncology follow-up scheduled. That is one hell of a silver lining.

NHSC ya later!

2009-10-14T22:31:00.001-07:00

It's official, bitches!

NewFNP received a certificate and a letter today noting that she has completed her service commitment. Hells yes she did -- a year ago! But newFNP is inclined to disregard the delay and feel thankful that her brand name nursing school was paid for and that her three years in community health indentured servitude offered her an education in and of itself.

In retrospect, worth it. Worth every tear and every ounce of frustration. But she's not running back to sign up for more.

Sunken treasure

2009-10-09T16:48:00.000-07:00

There are a few things which, if found in her bathtub, newFNP would wrap in a cloth napkin and tuck away in her lingerie drawer for safe keeping. These include a Harry Winston 3-carat flawless diamond, a bar of gold bouillon and a love letter from George Clooney begging for a second date.

What she would not keep is a year old Mirena IUD that had spontaneously expelled itself from her daughter's uterus.

Granted, newFNP does not have a daughter, let alone a daughter old enough to have an IUD, but she's quite certain that if presented with that scenario, she's not keeping the IUD as some progestin secreting family heirloom.

But this is exactly what happened. NewFNP's patient presented to have a new IUD placed but had no evidence that the IUD string hadn't ascended rather than the whole damn thing falling out. Did she see the IUD or feel the IUD expelling? She did not. Her only proof of expelled IUD was the return of a normal menstrual period after a menses-free year. Sadly, that is not grade A evidence. NewFNP unsuccessfully hunted for strings and then filled out the referral for an ultrasound to confirm expulsion. A uterus is, after all, designed for only one IUD at a time.

Her patient went home and got on the horn to make the ultrasound appointment. Her mom, also a patient of newFNP's, overheard the conversation and, with a sly smile on her face, presented her daughter with a daintily folded cloth napkin. Inside was her Mirena.

Why? Why wait? Why keep the IUD and not let one's daughter know that she is no longer effectively contracepting? Why keep it?

It's all so confounding for newFNP.

And hey -- let's just put that napkin in the trash, shall we? If ever there were a situation that called for cloth napkin wasting, this is it.

You're either in... or you're out!

2009-10-08T19:56:00.000-07:00

NewFNP does not love to start her day with a veterinary emergency. Three hundred dollars later, her dog is on the mend and stoned on muscle relaxants. NewFNP needs a more affordable vet.

She furthermore does not enjoy it when she leaves her convalescing dog alone, pushed the power button in her car and finds the tire pressure warning light illuminated when there is no discernible flattening of tires. Those lights just stress newFNP out! To make matters worse, the frigging Prius has a warning light for everything. Too dirty? Warning light. Country music? Warning light. Bad hair day? Warning light.

And then twenty-nine patients later, she can think of some other things she isn't super fond of.

For instance, a 39-year old male with copious purulent and possibly necrotic nasal discharge. It wasn't that newFNP wasn't fond of him. It was that she experienced more of a visceral olfactory aversion. This poor gentleman smelled like a walking abscess. It was challenging to be in the same room with him. This has been occurring for 6 months. NewFNP posits that he has neither a roommate nor a partner. She hopes that he just has a horrible sinus infection or an abscess and not some type of tumor sloughing off. Truly, the smell. She decided to send him to the emergency room which is when he broke her heart a little bit.

She asked him to call someone to take him as she felt she couldn't justify the ambulance ride. He called El Conejo who agreed to pick her patient up at clinic and take him to the ER. NewFNP asked for his friend's name so she could leave it at the front desk and have the reception staff direct him to the back office. Her patient didn't know his friend's real name -- just El Conejo, the rabbit. He never showed. Is it a shock? This man must be so isolated and lonely that he called someone whose real name he does not know to take him to the emergency room. Ouch. NewFNP fed the patient leftover potluck lunch while he was waiting, gave up on the rabbit and eventually put him in a taxi, a sure-fire guarantee that he'll arrive at the emergency room.

Then she examined a patient who told her that she had an allergy -- to hot water. Just hot water. Does she shower in tepid? What if it's cold out?

But what newFNP is fond of is her new cute and affordable (!!) shoe find: Tsubo. In the quest for fashionable and comfy, newFNP has struck pay dirt.

And now she can relax with her dog, eat lucques olives, drink some wine and watch Project Runway. And of these things, she is quite fond.

No. Just no.

2009-09-22T20:14:00.000-07:00

Fucking pancreatic cancer. It is a goddamn awful diagnosis and an exceedingly difficult one to make until it's too late.

Perhaps that is why newFNP's patient received her diagnosis when the tumor was already unresectable and had metastasized to her liver, intestine and lymph nodes.

NewFNP took one look at her today and knew that something wasn't right. She had lost way too much weight for that amount of time, and not in a healthy-appearing way. NewFNP had seen her six weeks ago and noted scleral jaundice. At that time, she drew STAT labs. Her acute hepatitis panel was normal, her bilirubin, alk phos, AST and ALT were sky high. NewFNP's colleague sent her to the emergency room where, during the course of her three-week inpatient stay, she received her terminal diagnosis.

She was born the year after newFNP -- she in in her 30's. She has four kids under the age of eighteen.

She has three to six months to live. If that. Her oncology appointment is in four weeks -- too long a wait when every week is one of the last she has to spend with her family.

NewFNP is absolutely fucking heartsick about this. This is a woman who was abused by her former intimate partner, who suffers with symptomatic myasthenia gravis and who has diabetes. NewFNP cannot believe that after all this woman has gone through, she is going to die.

NewFNP couldn't bring herself to say this to her. She is, after all, not an oncology NP and she didn't have a quantified prognosis in the very well-organized three-ring binder of information from the hospital. She told her patient that this is a very serious diagnosis, that the physicians in the hospital had determined that the tumor was inoperable, that there is no cure. She referred her to the medical-legal partnership to seek out health insurance coverage and, horribly, to draft a will when she is ready. (As though someone could possibly be ready for this activity given the non-theoretical impetus for doing so.) She referred her and her children to counseling. She counted on the personal connections of a colleague to attempt to facilitate a more prompt oncology appointment. She found a clinical trial that accepts Spanish-speaking patients.

Who is going to take care of her children? How is she going to have hospice care without insurance? How will she afford her pain medications? Who will take care of her children? NewFNP cannot imagine what would have become of her if her aunt had not raised her after her own mother died when newFNP was fourteen. It wasn't the right time to bring this up with her patient today.

NewFNP doesn't know what else to do. She cannot do much of anything. She hates that.

Reform

2009-09-17T19:29:00.000-07:00

Would it surprise anyone if newFNP were to say that she is a supporter of a public option for health care coverage? Because she is.

NewFNP does not understand the arguments against public health coverage. NewFNP thinks that Medicare is a pretty cool program -- certainly preferable to elderly people dying in the streets left and right. And although the reimbursement isn't great and the prescription drug coverage leaves something to be desired, if newFNP's 94-year old grandma needs to go to the emergency room, it's covered. If she needs to be evaluated for her hypertension, her doctor accepts her insurance -- her public insurance.

Another thing that oftentimes stumps newFNP is this vitriolic opposition to coverage for illegal immigrants. Um, sorry to be the one to tell you, but this country spends a shitload of money on the medical care of illegal immigrants. Lest anyone thinks that newFNP's clinic is full of native born Americans down on their luck, think the hell again. A large proportion of newFNP's adult patients are living here illegally. Some are applying for green cards and citizenship. Others are ineligible. For many, their children were born here. By and large, the parents were not.

NewFNP is very mindful that she is spending taxpayer money when she is ordering tests, referring to specialists and trying her damnedest to take good care of her patient's complaint within the walls of her clinic. But newFNP's time is well compensated -- those visits may be free to the patient but they are far from free.

In the absence of comprehensive and - let's be frank - rather harshly defined immigration reform, what exactly is the alternative?

Not treating someone's active TB because they are illegal residents? That makes little sense from a public health perspective as that adult living here illegally may spread TB to his child, who will in all likelihood go to a public school classroom where 30 other children may be exposed.

Or not treating someone's diabetes so that they can present to the emergency room in DKA or blind or with a necrotic Charcot? That's not going to save anyone any money and it sure as hell isn't going to prevent any suffering.

NewFNP doesn't know the answer. But she knows that bankruptcy due to medical debt is fucked. She knows that her patient today, a 40-something year old status post metastatic choriocarcinoma and a citizen, is scared to go to the emergency room for severe abdominal pain because she is already receiving daily phone calls over a $1500 outstanding debt.

And she sure as hell knows that preventing an illness is far, far superior a plan from an economic, an emotional and a future-oriented perspective than is treating a chronic illness, amputating a leg, tracking down an outbreak of communicable disease or treating anything other than an emergency in an emergency department.

Is there anyone at all protesting this plan who is uninsured? Seriously -- anyone? Have those who oppose a public option - even if it is only for citizens - ever met someone who suffered as a result of lack of insurance? Are they utterly lacking in empathy?

Not to be overly dramatic, but is this the America in which we want to live?

Pura vida

2009-09-16T20:38:00.001-07:00

NewFNP has been home from Costa Rica less than forty-eight hours and she already wants to go back.

Lost in translation

2009-09-07T22:48:00.000-07:00

Misspelling is common is newFNP's clinic. Chlamydia is tough to spell. Gonorrhea is no picnic either. And don't even get newFNP started on Kwashiorkor or borborygmi.

Generally, however, the misspellings have an obvious translation. Thus, newFNP was thrown for a loop when she saw a chief complaint of "Cephalus Check."

Cephalus??? What happened during that hunting trip when Eos kidnapped him that he needs to come to a free health clinic for a check up?

But seriously... cephalus? Was newFNP asleep for that lecture? Is that a condition newFNP missed? It is hydrocephalus? Shouldn't this patient be at a neurologist?

What a sophisticated misspelling it ended up being.

The patient was requesting a test for syphilis -- just regular old syphilis. But newFNP likes the way this front-desk staffer was thinking! Use the 'ceph' root. Give newFNP a little taste of the 'ph.' Hell - make her think about mythology during a humdrum clinic day.

That's right, yo, you gotta class that shit up a little bit!

Dementia praecox et Cocoa Brown

2009-09-04T20:50:00.001-07:00

Would it come as a surprise to anyone if newFNP disclosed that Cocoa Brown had serious mental illness? It pains newFNP to see her suffer.

Cocoa Brown has schizophrenia and boy does she ever struggle. When she feels like she needs a break from the world, she goes into the emergency room and tells them that she is suicidal. She has attempted suicide in the past, she is marginally compliant with her anti-psychotic because she frequently runs out before she makes it to the pharmacy for a refill, she has a history of drug abuse, she is precariously housed and, frankly, if she wasn't in psychiatric care, she would likely be actively suicidal again.

Cocoa Brown has also developed urinary incontinence, perhaps as a result of her anti-psychotic, perhaps her weight, perhaps a combination of the two.

Do. Your. Kegels.

During Cocoa's most recent inpatient mental health stay, she fell asleep in the day room and had an accident. To hear her tell it, a nurse kicked her chair and gave her a bit of shaming about the accident. Cocoa Brown described the conversation that subsequently ensued.

Cocoa Brown replied, "What the fuck are you waking me up for to tell me that. Everybody knows I can't control that!"

(NewFNP imagines that the nurse pauses at this point, wondering what her next move should be. Cocoa Brown, however, is undeterred.)

"You don't wake me up for that! You wake me up when it's fucking time to eat or take meds, but you don't fucking kick my chair and wake me up for that!"

(Amen to not missing a meal. On a roll now, newFNP imagine Cocoa Brown pointing an index finger at the nurse.)

"The next time you wake me up for something like that, I am going to knock you the fuck down!"

Lest anyone think that she is not serious, may newFNP remind you that Ms. Cocoa Brown previously attacked an ex-partner with an exposed-nail ridden board.

NewFNP could have given her a lesson about behaving properly. Instead she simply said, "Cocoa, I hope to never hear those words directed at me." To which Cocoa replied, "Aw, newFNP, you know I'd never say that to you."

Whew!

However, the scenario does bring to mind several salient points:

- unlike Cocoa Brown, newFNP would like to be awakened if she is dozing off in a puddle of her own urine.

- mental illness causes people to behave in unpredictable, non-normative ways.

- mental illness has a devastating effect on people's lives.

Cocoa Brown will never have a normal life. Her schizophrenia will likely continue to affect her life in negative ways. She is poor, she is socially marginalized, she has not benefited from vocational therapy or social rehabilitation. The internal and external worlds in which she lives are very different from most people's.

But newFNP loves taking care of her -- as much as she can. Pill refilling, blood pressure monitoring, syphilis treating, and in offering a friendly and peaceful exam room where Cocoa can just be Cocoa.

Guiding Light

2009-09-01T22:12:00.000-07:00

In newFNP's dreams, her clinic would utilize the in-speculum pap light. What a world of difference those lights make.

Alas, despite her pleas, newFNP's clinic employs the bulky swan-neck pap light and right now newFNP's clinic is experiencing an epidemic of pap light demise. The storage closet is a pap light graveyard. Is it simply an issue of a burned out bulb? Did the lights just collectively decide to throw in the towel after years of vag lighting? NewFNP doesn't know, but what she does know is that she needs to put some light on the subject when it's pappy time.

Twice today, newFNP sat down on her rolly stool and went to grab the light only to discover that it wasn't in its corner. (One may wonder what this says about newFNP's powers of observation that she was already ready to roll before she noticed that the light wasn't there.)

The first time, newFNP tasked her MA to scrounge up a light.

The second time, newFNP said "fuck it," put the speculum in place and grabbed the otoscope from the wall, aimed it towards the center and identified the cervix. After all, it's not as though the vagina is some vast cavern and one needs some type of spelunking light by which to guide the journey. The anatomy basically regresses to the mean. Thankfully, her patient today was no anatomical outlier.

NewFNP is nothing if not handy in a pinch.

A very happy 4th anniversary

2009-08-29T08:52:00.001-07:00

Today is the 4th anniversay of newFNP. She is hardly new anymore, is she?

NewFNP's anniversary week has been graced by a long-time patient welcoming a new baby girl, another long-term patient hospitalized and dying, and by the always exciting return of one Ms. Cocoa Brown. A story for another day.

Because today, on her 4th anniversary, newFNP is dolling herself up for a celebration. She is so appreciative that her cousin and his fiancee scheduled their wedding on such a special day.

To her favorite ice climbing, engineering, post-doctoral molecular geneticizing couple - mazel tov.

Milk it does...

2009-08-20T22:03:00.000-07:00

Several weeks ago, newFNP stepped in to do a well child exam on an 18-month old well known to her. NewFNP takes care of her grandma (scleroderma), her grandpa (missing frontal skull bone after 2 infected craniostomies following a truck tire exploding and striking him in the head) and her mother (21-year old with uncontrolled hypertension on 5 daily medications including clonidine with a history of methamphetamine use, now abstinent).

When newFNP saw this child's hemoglobin, her heart sank. It was 4.9. The child's skin had an unhealthy grayish hue.

Repeat it, newFNP instructed her MA. Her blood was pinkish. The repeat hemoglobin was 4.5.

Shit, newFNP muttered.

Is it leukemia?, newFNP asked her colleague. It's leukemia, he responded. 4.9 is fucking low.

NewFNP went with the grandparents into the exam room as the young girl's mom was at work, where she is six days per week.

NewFNP told them that she needed to send the little girl to the hospital and that she was concerned about leukemia.

Never before has newFNP been on the verge of tears in an exam room. But she knows this family and she knows that they have been to hell and back and that they all still suffer and she loves taking care of all of them -- that is one of the joys of family practice.

She called the patient's mom and told her to come immediately to take her daughter to the emergency room. The patient was crying, her mom was crying, her grandma was crying. NewFNP was barely holding it together.

Hours later, newFNP spoke with the patient's mom to see what had transpired.

What had transpired was the this little girl was drinking upwards of 50 ounces of milk daily. She didn't have leukemia -- she was a lactoholic. She was discharged from the ER with iron. No transfusion, no nothing. Follow up and repeat the CBC in 2 weeks. NewFNP couldn't believe it.

4.9. From milk!??!!**

Her repeat CBCs have been greatly improving, her pallor has disappeared and she appears to be not at all suffering withdrawal from her milk dependence.

Pass it on.

____________________

**When kids drink too much milk, they don't eat iron-rich foods -- or much of any foods for that matter -- and they may have intestinal irritation that causes asymptomatic blood loss in the stool thus causing anemia.

Broken heart

2009-08-05T10:25:00.000-07:00

NewFNP was awaiting the EKG results for her 20-year old methamphetamine treatment seeking patient when her awesome lab supervisor came out and handed her this:

NewFNP was a little stunned. Q-wave in III. rR' in V1-V3. A 20-year old guy. "What the fuck," newFNP thought to herself. Her lab supervisor helpfully offered that the young man had a large vertical scar to his chest.

Ah, cardiac surgery. If newFNP were a cardiologist, she might have been able to identify the EKG changes immediately. Alas, she is not so she was left to question the young man as to his cardiac history.

She asked him to tell her about his heart surgery. He replied that he had never had heart surgery. Hmmm. NewFNP then inquired as to the etiology of the large suprasternal scar.

"Oh yeah," he replied. "I had a heart transplant."

"A heart transplant??!" newFNP responded and then inquired if he was taking any medications. He replied that he was not, leading newFNP to deduce that he was likely mistaken as to the nature of his surgical procedure.

She asked him why he may have had heart surgery as a child. He was unable to tell newFNP.

NewFNP conducted his cardiac exam which was -- not surprisingly -- abnormal. His pansystolic murmur over the aortic region obliterated S2. His murmur over the pulmonic region was palpable. The other murmurs were less extraordinary.

At this point, newFNP was stumped. In retrospect, she should have put it together. Pulmonic stenosis. Childhood cardiac surgery. But newFNP has never seen anything like this and she just couldn't put the pieces together.

Thankfully, the young man's dad showed up to the clinic and explained that the patient had Tetralogy of Fallot repaired when he was 18-months old. Prior to the repair, he had multiple Tet episodes leading to numerous hospitalizations. The surgical repair was delayed due to a lack of health insurance. As a result, he spent his first 18 months lacking oxygen.

It is fair to say that this young man is not bright. In her interactions with him, newFNP often sensed that his IQ was quite low. Now she had a reasonable explanation as to why. The bummer is that because his IQ is so low, he cannot appreciate the consequences of his actions like others might.

For instance, methamphetamine is cardiotoxic. His heart is repaired, but not normal. This combination might give someone else pause. It was clear that this young man did not understand the potential impact. His parents understand though. It was difficult to see the sadness and desperation in their faces as their son averted his eyes and spaced out during the visit.

He is set up with a cardiology referral, an addiction treatment referral and a list of clinics where he can have neurocognitive testing completed and get referred to vocational education. He still doesn't understand why these appointments are important. He has other things to worry about. His girlfriend wants to have a baby. His friends want to go out and party. He has no concept of consequences.

Heartbreaking.

When you're sliding into first...

2009-07-29T10:12:00.001-07:00

There are often times when the chief complaint truly misses the nuance of what the real concern holds in store.

For instance, a chief complaint of diarrhea in a child is not so common, not so nuanced, not so big of a deal.

(As an aside, newFNP had a pediatrics professor who invariably pronounced the word diarrhear, which so brought glee to newFNP and BostonFNP during a long day of dry lectures-- and it still does to this day!)

But what if diarrhea is not just diarrhea? What if it is encopresis? Well then, you're in for a hell of a different appointment.

The history went something like this: the six year old boy was toilet trained, but then he started soiling. When he's with mom, she has him wear diapers, even to school. When he's with dad, he is instructed to go commando so that he is forced to "learn to control himself." Both interventions wholly unacceptable and antithetical to appropriate treatment.

To be fair, this is in part the clinic's fault. He had been seen twice before for the same problem, had received minimal guidance and had no improvement in symptoms. No big surprise there. It's a confusing diagnosis for parents. It's tough for primary care providers to give diagnoses such as this the appropriate care given that it involves greater than 10-15 minutes, education from the provider and counseling from an actual counselor.

What makes this even more difficult is when the kid's father is intoxicated in the exam room and when the kid's mom is absent - both from the appointment and largely from his home life as she works and spends an extraordinary amount of time volunteering at church. It was clear to newFNP that the kid was used to his dad being drunk when she watched him call his name and gently slap his face in order to rouse him when she called them in from the waiting room.

All throughout the encounter, newFNP was concerned about neglect. But the kid was clean, he was growing appropriately, and he related well with newFNP and with his father. His future might not be the brightest given the family history of alcoholism and the poverty, but poor alcoholics raise healthy thriving kids so we'll have to institute a prospective study to see where this kid goes. NewFNP decided that it wasn't neglect - that it was ignorance regarding the problem and lack of support.

NewFNP gave the appropriate education, both verbally and in written form, instructed the father that both the diapers and the sans undies must stop A.S.A.F.P., ordered an x-ray, prescribed Miralax and toilet times, and hooked the family up with free counseling. This took about 40 minutes.

Worth it. They showed up to their counseling appointment the next day and have follow-up scheduled.

Fat

2009-07-11T16:36:00.000-07:00

NewFNP is back from the most restful time she ever had in the state where she attended graduate school. Her school years there were full of studying and bad weather and really bad weather, whereas her Independence Day long weekend was full of tranquility, mild weather and relaxation with grad school pals.

And now she's back and has questioned more than once why on earth she lives in the urban jungle when tranquility and waterfalls are available to her?? Ah yes, proximity to Barney's.

Her first day back in clinic was also her first day with her second ever student from her alma mater. It was a day filled with tough patients.

There was the 2-month old infant who would not make eye contact. Is it a retinopathy? Is it an early indicator of autism? NewFNP isn't sure. Ophthalmology consult!

Then there was the Mirena that twice fired prematurely with no assistance form newFNP. NewFNP felt like a nervous lover - and in front of a student! Eek. Her student later asked newFNP if that was a normal amount of nervousness for an IUD insertion, to which newFNP replied, "For newFNP or for the patient??"

Then there was the 20-year old G1P0 who was far more interested in picking at her thick French tips than participating in her prenatal care.

And finally there was the 19-year old G1P0 with a BMI of 55.5. No joke. She is 5-foot-1 and 294 pounds at 36 weeks gestation. She was 254 at her first prenatal visit.

NewFNP frequently reads lay articles and medical journals with stories and studies and statistics about the obesity epidemic. Fourteen is the new ten. Children are at risk. This will be the first generation to die earlier than previous generations because of the effects of obesity. The south is fat.

OK. NewFNP gets it - as a nation, we're fucking fat.

But please, please. Tell me just what in the world providers are to do? These are the avenues newFNP has attempted with her portly nullip:

1) just the facts, ma'am (health of mom and baby, labor complications, gestational diabetes risk);

2) supportive listening and encouragement (yes, it's hard to change our habits but you're doing this for your baby and yourself; yes life has dealt you a rotten hand -- let's change that for you and your baby!!);

3) stern lecturer (this has to stop - we are talking about the health of you and your child);

4) Richard Simmons (have you tried our prenatal yoga class??);

5) throwing the fruit punch in the trash.

And this is with one patient.

Obesity is a public health problem. This is not a problem that individual providers can address on a large enough scale to prevent and treat obesity. It's not that newFNP doesn't talk to her patients about their weight - she does. She talks to normal weight patients, underweight patients -- all 3 of them, and overweight patients about their weight. But that isn't enough.

Children are fed trash in public schools. WIC -- for all its great work -- gives away coupons for trashy foods. Parents give in to children's pleas for junk food. Poor urban areas are full of fast food options and liquor stores. Poor urban areas are not safe for outdoor play and exercise. Fruits and vegetables are expensive.

So what are we going to do? NewFNP is open to suggestions.

-------

Congratulations and love to BostonFNP and BostonJD.

OB, oh boy!

2009-06-26T20:52:00.000-07:00

It pleases newFNP that she continues to experience new challenges in clinic. Otherwise, the work gets a little too rote. Thankfully, newFNP's prenatal practice has been supplying her with a couple of not taught in school-style scenarios.

In the past week, newFNP has had five patients on the verge of labor. Generally what happens is that newFNP educated patients on when they should go to labor & delivery and, with the exception of her eighth-grader in labor, that is what happens.

Not so much this week. One patient presented for her repeat c-section, ineligible for VBAC due to her first c-section being conducted vertically, checked herself into the hospital and then checked herself out, only to drive to another hospital where she had the cesarean. Another patient presented to her c-section appointment because her fetus is stubbornly breech, only to be turned away and instructed to return in a week. NewFNP scheduled this c-section according to the hospital's protocol for breech position, not according to her own whimsy. Whatever.

Finally, not once, but twice in the past week, newFNP has had patients present to the clinic in labor. Her most recent patient (G3P2) was three days post-dates and had a urine dip that screamed UTI and dysuria to boot. To top it off, she was contracting every three minutes in the exam room. She was laughing through the contractions and they were only lasting about 20 seconds. NewFNP, however, was not laughing.

Here was newFNP's conundrum. It was simple really: treat the UTI with some Rocephin and then send her to labor delivery or just send her to labor & delivery. Truly, newFNP thinks that either way would have been fine. But she prefers to TCB in the clinic, rather than shuffling her patients off with business left to take care of.

NewFNP called her Family Practice MD colleague who advised her to do a vaginal exam to assess for cervical dilation and effacement, give the Rocephin based on what was going on all up in that and go from there.

Here's the problem: newFNP doesn't totally trust her cervical exam. She just hasn't done enough of them on pregnant ladies in labor. Sure, if she could put her head in there with a miner's light, she could easily tell if that action is dilated. But on a 232-pound lady who is 10 months and three days pregnant, the exam is not so easy for newFNP. Nonetheless, newFNP strode back to the room, sterile gloves in hand, and proceeded to examine the hell out of that cervix.

And folks, that was a good cervix to assess. NewFNP felt 5-6 centimeters of dilation and nothing but head. NewFNP's patient, shocked, just kept laughing through the contractions. NewFNP called her MA to deliver the Rocephin, called the prenatal coordinator to deliver the taxi voucher as her patient had driven herself to her clinic appointment, had her call her truck driving husband and ask him to turn that action around, and sent her on her way.

She gave birth to a healthy 9-pound girl a few hours later.

The fifth patient just went to the L&D floor as directed.

So, all in all, 20% of these ladies had labors that went down as newFNP had anticipated. Doesn't matter. All that matters to newFNP are healthy moms and babies.

Girl, you'll be a woman (far too) soon

2009-06-20T16:32:00.000-07:00

NewFNP is just going to put her bias right out there: if not a single teenager ever got pregnant again, newFNP would be just fine with that. Sure, having a baby when one is in the 10th grade is not the end of the world. It doesn't absolutely mean that one will never, say, graduate from high school or attend college.

But it sure as shit makes it more likely.

NewFNP concedes that it is utterly possible that the 16-year old sitting in her exam room, pregnant with twins, was not necessarily college-bound to begin with. Most of her patients do not go on to college, but newFNP makes it a practice to plant the seed in her pediatric & adolescent patients that they have options and that college is a very good one indeed. NewFNP recognized her patient's mom as one of the women who regularly sells champurrado outside the clinic from an orange Igloo container. Maybe college has never been thought of as a possibility for her children, never been discussed in the family. Maybe grandchildren will bring more joy than will the pride associated with watching your child succeed academically - newFNP just doesn't know.

NewFNP moved between the medical and social histories with this patient. Tenth grade. Lives at home. Planning to continue the pregnancy. Medical history insignificant until now.

When she inquired as to the father of the twin fetuses, her patient replied that he was involved.

Great - that is a good start.

"Is he in school?," newFNP inquired.

"No," her patient replied, eyes averted.

"What is he doing?"

"He's working."

"How old is he?" newFNP asked.

"Twenty-three," came the sheepish reply.

Somewhat shocked, newFNP turned to her patient's mom and asked her what she thought about this. She replied that she thought her child's Casanova was a good guy.

NewFNP almost fell off her rolly stool. It is a situation such as this in which newFNP imagines herself going vigilante in her hypothetical parenting world. This is a man and a girl. This is statutory rape. This is one of the many reasons that newFNP is a huge fan of the birth control pill, the IUD, even the shot (of which, truth be told, newFNP is no real fan).

Her patient's mom told newFNP that she had instructed her daughter to be careful. Be careful?? Has this mom never met a twenty-three year old man before? Because newFNP has, and she knows that they are horny motherfuckers.

NewFNP referred the girl to high-risk OB and to pregnancy case management. She reminded her that quitting school was not an option, that she would, in short order, have two children to support and that those children would look to her for guidance.

It wasn't one of those encounters that newFNP walked away from feeling hopeful about the future or inspired by her work.

She just felt sad. And disappointed. And angry. At herself for not being a better counselor, at the mom for not helping her daughter get contraception and for condoning the relationship and at the guy for dating a high school student.

Out of the rut, follow the gut (instinct, that is)

2009-06-12T22:19:00.000-07:00

NewFNP has been caught in the hum-drum of sameness at clinic. Paps, prenatals, diabetics, URIs. These are the norm of clinical practice, but the routine gets a little drab. Don't get newFNP wrong - she doesn't want to work in a emergency room, but she does like a little change-up here and there.

She got it.

NewFNP was doing an abdominal exam during a well-adolescent visit. The kid was fourteen, had no medical history to speak of and had no complaints. Nonetheless, the instance newFNP palpated his belly, her internal alarm sounded.

This young man was not especially skinny - just average with a smidge of baby fat. Had he been thin as a rail, newFNP would not have been so startled when she felt his abdominal aorta pulsating very prominently and pulsating a full two finger breadths to the right of the umbilicus. She attempted to measure the aorta and estimated about a three-plus inch width.

NewFNP spent a while running this through her mind. She didn't feel a mass and she could not determine the direction of the pulsation. The only thing of which she was certain was that this exam did not feel right.

She got Dr. Dual-Ivy-League-Degrees to consult -- she agreed that it was an unusual exam.

Maybe this is normal for him, but son-of-a-bitch if it's an aneurysm. What are the odds at fourteen years old? Un-frigging-likely. Nonetheless, newFNP trusted her gut and sent him and his gut for an ultrasound. She is anxiously awaiting the results.

Dress code violation

2009-05-29T21:25:00.000-07:00

The inappropriate t-shirt trend has followed newFNP to the research clinic. The reach of the inappropriate t-shirt is, apparently, far and wide.

When newFNP saw her patient filling out forms in the waiting room, she did note that his shirt said "F.B.I." across the chest. NewFNP naively thought that this gentleman seeking to participate in a research study about methamphetamine addiction was perhaps showcasing a touch of irony.

Not so much. Upon closer inspection, newFNP notes that underneath the "F.B.I.", the shirt read "Female Body Inspector." Classy. The only female body part newFNP will let this fellow inspect is her stank eye.

But the self-appointed Female Body Inspector had nothing on the wildly inappropriate t-shirt that another research participant was wearing. This shirt was a walking advertisement for the metal band Cloven Hoof. This shirt featured a graphic of a mullet-man orally pleasuring a woman. Charming. NewFNP gets it - figuratively - and she is none too pleased.

When newFNP gets dressed in the morning, she does the usual mirror checks: no VPL, no muffin top, no boob overflow, no totally fucking offensive t-shirt. Check, check, check and most definitely check.

I mean really. Cloven Hoof? Cunnilingus? What makes someone purchase such a shirt? And then what possesses someone to wear that shirt to a medical clinic?

Yuck.

Action!

2009-05-23T20:22:00.000-07:00

What's up, nurses? We're fucking famous, that's what. Or maybe nursing leaders are in cahoots with the entertainment industry to make nursing appear to be a more attractive profession in the face of a horrible nursing shortage.

Not one, but two new TV shows with nurses as lead characters!! Showtime's Nurse Jackie and TNT's HawthoRNe.

NewFNP's hope is that the TV shows will do nursing justice and that the characters will be interesting and complex and funny and smart. It's newFNP's fear that a recurring dynamic is going to be the physician-nurse tension as is showcased in the HawthoRNe commercial. That dynamic is tired.

NewFNP's money is on 'Nurse Jackie'. It has Edie Falco, it's on cable and on the same network that brought us 'Weeds' and 'Huff', it has a nursing student character and it appears to have been thoughtful in its character development.

And if the show's writers need any technical assistance with the science and art of nursing or with story line development, newFNP shall avail herself to them!

You down with PCP (yeah, you know me)

2009-05-13T12:58:00.000-07:00

It cannot be stressed enough - the 30th patient of the day must not - repeat not - be difficult. That patient could be clinically complicated but personally reasonable or that patient could have a "gimme" diagnosis. NewFNP's favorite is UTI, but she could go for an otitis media or a fungal derm as well.

NewFNP isn't sure how to triage for this when scheduling appointments, but if she could develop an algorithm for optimal patient scheduling that ruled out end of day challenges, she could retire and buy an S4 and some Tory Burch tunics.

As newFNP perused patient #30's chart before entering the room at 4:40 to begin said patient's complete physical, she noted that another provider had charted "PCP abuse."

PCP? NewFNP glanced at her watch. She had not, in fact, used her flux capacitor and time travelled back to 1983. It was firmly 2009. She imagined that the demand for PCP would be minimal and that this patient's dealer might have a 2-for-1 special or a sign that screamed, "PCP - no waiting!!" whereas the lines for meth and crack would loop around the block. Of course, truly, newFNP has no frigging idea about PCP procurement. And even more significantly, she has no idea about PCP addiction treatment.

So newFNP goes about the social and medical histories which, as one might imagine, were both colorful and sad, and got around to asking about the PCP. She had been smoking PCP on and off for over 20 years.

"When was the last time you used PCP?" newFNP asked?

"Well, it stays in your system for a long time," #30 replied.

Hmmmm. It's an answer, yes, but it's an answer to an entirely different question.

"Oh, OK," newFNP responded. "So about how long ago was the last time you used PCP?"

"I want to stop," #30 replied. "It's hard to be a mom."

NewFNP imagines that it is hard to be a mom and that anyone would want to stop PCP use. Still, that nagging little question was stuck in newFNP's craw. NewFNP acknowledged her patient's desire to stop and assured her that she would receive a referral to behavioral health/addiction medicine treatment. But she had to ask.

"I'm sorry but I'm still unclear as to the last time you used PCP," newFNP gently prodded.

"I told you already!" #30 exclaimed.

"I don't think you did," newFNP stated. "You told me that you wanted to stop and that PCP stays in your system for quite some time. But I don't know how long ago you used."

"A month ago," she stated, as easy as 1-2-3.

The thing about PCP is that its lore is full of horror stories - people thinking they can fly while intoxicated, people exhibiting superhuman strength, people having delusions and behaving violently. And it's an hallucinogen, a class of drugs for which there is a paucity of documented treatment modalities.

So, after a month of not using in the face of all the same life stressors as are always there, how does someone maintain abstinence?

NewFNP gave her a counseling referral and some encouragement, but that's not really enough. Unfortunately, it's all many primary care providers have to give. Mental health and addiction treatments are expensive and not adequately covered under insurance plans and certainly not under this woman's public insurance plan.

Maybe newFNP should refer people to Intervention - let Jeff or Candy give it a whirl.

Rack 'em up

2009-05-04T20:14:00.000-07:00

NewFNP is back from her conference and - you know - nothing says 'welcome home' like a diagnostic mammogram! As she prepared for her appointment and dutifully neglected to deoderize and moisturize, she reminded herself not to worry until there was something to worry about. She arrived at her fancy-pants medical center, registered, donned the wristband and was called back to get changed.

She changed into her seersucker gown in the mammography center dressing room and glanced at herself in the full-length on her way out. The mammo-gown was actually flattering. They must have had DVF design the fucking thing.

Having never had a screening mammogram, newFNP is not quite certain as to the extent of its torture but she will say this: the diagnostic mammo is no way to get initiated into the world of breast imaging. Eight views - none pleasant.

NewFNP didn't realize that, in addition to the breast tissue, the mammography technician would need to manipulate her xiphoid process into the images.

When her sweet as could be technician finally got newFNP's breast flattened so as to resemble a fucking crepe, she - in all seriousness - told newFNP not to move.

"Honey, I wouldn't dream of it," newFNP responded. After all, newFNP rather likes having two generally symmetrical breasts and felt quite certain that any attempt at escape would be a) futile and b) mutilating.

Although newFNP made light of her situation with her technician, she couldn't help but to feel a twinge of worry. Her face must have betrayed her worry and a kind lady in the waiting room commented on what a horrible waiting room we were in.

NewFNP agreed. The woman told her that she had her first mammography at 37 and that her mother had died at a young age from breast cancer. She went on to say that she had had "a thing" removed a few years ago. It was benign.

"I have a thing," newFNP told her. Although newFNP knows it is benign, it felt oddly good to unburden herself to this lovely and kind stranger.

"You do not worry until there is something to worry about," the woman told newFNP, echoing her very own thought. "That is not denial," she said as we stood together to schedule our next appointments - hers in one year, newFNP's in two days for ultrasound.

(NewFNP made the follow-up appointment, but could not help but to think that she is caught in the middle of a CYA-medicine spiral. Is the fine needle biopsy next?)

NewFNP and this woman finished their boob and metal sandwiches at the same time and walked down to the valet together. As the valet drove her car around, newFNP commented that we have the exact same car.

"It was meant to be," she said and gave newFNP a caring smile that made her believe it was true.

Taking it (the Big) Easy

2009-05-02T15:02:00.000-07:00

The last time newFNP was in New Orleans, she was 22, on a meandering cross country road trip which had such highlights as the Carlsbad Caverns, Graceland and a variety of Shoney's restaurants, and was bunking in a bright pink hotel called The Frenchmen.

This time she is at a conference - an addiction medicine conference - at the Hilton.

Note to the addiction medicine conference organizers: there is a W just a block away. Think about it.

Anyway, the highlight of the conference so far may be the following patient quote shared with the audience of listeners at a lecture about stimulant use and hypersexual behavior. The patient, noting his inextricable link between buckwild sex and cocaine use lamented, "I guess I'll just have to get used to sex without the hookers and the drugs."

The quote is funny, but newFNP acknowledges that is problem is, of course, not.

NewFNP did make a quick afternoon escape from addiction to see a super great/creepy exhibit at the Audubon Insectarium and to sample some local cuisine: she had fried alligator (and a salad) for lunch.

Yum.

Not so lovely lady lumps

2009-04-13T21:56:00.000-07:00

It's been a long time since newFNP has been on the business end of a cytobrush. A year, in fact. But today was the day for newFNP to go from provider to patient and shimmy down the table into the stirrups for her annual exam.

When newFNP was in training, it was one of her articulated goals to perform the pap well, with the least amount of discomfort possible. NewFNP has achieved that goal. Her patient frequently tell her that they barely felt a thing - it makes newFNP so proud.

In order to achieve her gingerly executed pap exams, newFNP uses the cervical spatula and mascara wand combo and performs 1/2 - 1 turn of each. She goes from 12 o'clock to 6 o'clock with the spatula and makes a turn with the brush adequate to touch on most areas of a parous cervix. If she sees an area of suspected abnormality, she gives that a swipe as well. Throughout the process, she uses a light touch.

NewFNP's OB/GYN, on the other hand, uses the broom cytobrush, aka the cervical pitchfork, and makes about 75,000 full-force turns with that SOB. She clearly does not believe in the light touch and her "a little cramping here" warning is an understatement indeed. But fine. It last for six seconds and is over.

What is not over is the wait for newFNP's diagnostic mammogram.

NewFNP is certain that whatever is embedded her breast tissue is a fibroadenoma. She is certain that it is not cancer. But now she has to have a boob and metal sandwich because the seed of doubt has been planted and her OB/GYN encouraged her to get that frigging thing done without delay. And she's kind of pissed because of course it will be nothing yet she will have had to have her never-lactated, full-density breast all squished up in order to have the reassurance.

Ouch.

And nothing makes a lady feel old - prematurely old - like having a goddamned mammogram.

The world is your oyster

2009-04-11T15:45:00.000-07:00

When newFNP decided to become an NP, it was really because she wanted to take care of patients in a community health setting.

Done.

So when that gig burned her out, she looked around to see what else was out there. Her research position just happened to be waiting for her. Serendipity.

So now newFNP alternates between mellow, organized, important work days and hectic, clusterfucked, important work days. It's pretty cool.

And that is a pretty cool part of being a health care professional.

We have options.

Both positions have their positive aspects and their negative aspects.

At the community clinic, newFNP practices independently. She is an authority on certain aspects of care. She makes connections with patients and nurtures those connection as best she can. Yet she is expected to see 30 patients daily. Her patients wait hours to see her. And did she mention already the utter clusterfuck in regards to organization (or a lack thereof)?

At the research clinic, newFNP is really, truly treated well by her supervisor. She has more than adequate time with each of the research participants. She is learning about conducting research in an academic environment in which doing things correctly is the respected and expected modus operandi. She is learning a lot about drug addiction and is appreciating the importance of discovering new treatments for it as she meets with and learns about her patients and their lives. And there is a crazy delicious burrito stand mere footsteps away. Yet she makes no independent decisions, which, for newFNP is kind of a drag. That's the only real downside. Perhaps that will come in time.

As soon to be NP grads are hitting the job market, newFNP would offer this speck of advice: take the tough job first. Work in an environment that challenges you to become a better, more skilled provider. Learn. Sweat. Make mistakes. And, after a few years, look around and see what is out there.

Fashion disaster

2009-04-06T21:23:00.001-07:00

NewFNP long ago gave up her white coat. Too stuffy. Too many cheaply sewn buttons falling off and too little desire to mend. Too much unflattering hip-spread look. Plus, it spent quite a while in the cargo area cum unwanted goods graveyard of her car and newFNP kind of just forgot about it. She now just rocks whatever outfit she's rocking that day and, for the most part, it's all good.

Imagine, then, newFNP's chagrin when she finished a pelvic exam and noticed that her right sleeve felt a little heavy as she exited the room.

She glanced down and noted a big glob of speculum jelly adorning the sleeve of her crisp celery-colored J. Crew cashmere sweater.

Son. Of. A. Bitch.

Quickly and with a slight shudder, newFNP shut down the horrifying thoughts racing through her mind and told herself, again and again, that the speculum jelly now seeping through the soft cashmere yarn and quite possibly tickling her silky smooth wrist skin was, in fact, sterile. It was leftover jelly from the tray which newFNP uses to lubricate the speculum, not jelly from the used speculum itself.

It was from the tray. It was tray jelly. Not speculum jelly. Tray jelly.

No matter the source, newFNP was none too keen on having jelly on her cashmere. She washed it off, scrubbed off her wrist and - with it - her morning dab Fresh 'Sugar' fragrance, rolled up her sleeves and went about her day.

A sweet rack

2009-03-24T18:51:00.000-07:00

Dude.

NewFNP is totally cool with mental health days. Go to the Korean Day Spa for a naked lady Rub-n-Scrub and shed that nasty dead skin! Go see I Love You, Man and eat a large popcorn. Sleep. Whatever.

But do not be newFNP's MA and call in sick when you are, in fact, getting new boobs.

Sure, go ahead and get your new knockers. Whatever. Your life is hard. Your soon-to-be-ex-husband is a dick. NewFNP understand the urge to make a change when a relationship ends. But take a day and get a frigging facial, a hair-do and some airbrushed Coach nails.

But when you are having cosmetic surgery, you should take a vacation day (or seven). You should not be the employee that burdens her colleagues for boobs. And just how much is newFNP's clinic paying these MA's, for the love of God, if they are taking sick days for rack enhancement?!!

Honestly, newFNP just does not understand the desire for two inflated saline balloons in one's chest. Just get some boob cutlets and a push-up bra and call it a day. Total cost - fifty bucks. Less if you hit up the semi-annual sale at VS.

But even more of a bummer is that newFNP has really felt like this employee was committed to the team and understood the importance of her role.

And that changed today. Possibly even as much as her MA's new cup size.

Bring it.

2009-03-11T21:15:00.000-07:00

There are times in everyone's role transition in which they wonder if they are, in fact, cut out for the career they chose.

NewFNP had several such instances in which she thought - whoa pal... perhaps law school.

The first involved a patient who had a horrendous necrotic pressure sore that was so deep, it almost exposed the bone. This woman also had MRSA which meant that all staff were on contact precautions which, in newFNP's training hospital, consisted of a mask, gloves and a plastic gown.

It was the end of the day's rotation and newFNP had been busy as hell. She hadn't eaten. She was tired. And the smell of that pressure sore plus the tenting of the skin as the physician cut away necrotic tissue plus newFNP's hunger plus the millions of people in the room causing increased temps (and smell) plus the plastic precautions gown equaled newFNP sitting on the floor with her head between her knees in an attempt not to pass out.

A successful attempt, but clearly not a shining moment in student nursing history.

Another involved a patient who had undergone a partial pneumonectomy and, for reasons that now escape newFNP's memory, had failed to heal well. As a result, he had what is best described as a gill-like slit in his side that moved in a gill-like fashion when he breathed. And in that gill-like slit, there were strings of mucous that would quiver during respiration.

The vivid recollection sends cold shivers down newFNP's spine.

NewFNP left the room and told her preceptor, "I don't think I'm cut out to be a nurse" to which her preceptor raised one eyebrow - her way of saying that she disagreed.

NewFNP wrote about another unsatisfying olfactory experience three years ago. NewFNP recalls feeling so disheartened. How on earth would she take care of her patients if she could not even observe this procedure and remain on her feet? she wondered. NewFNP's consulting physician attempted to console her by confirming that that was, in fact, a hella smelly abscess but it didn't really make newFNP feel much better.

NewFNP has come a long way, baby. In these past three and a half years, newFNP has incised and drained her fair share of abscesses, but for the past year, the abscesses had dried up.

Until today.

When newFNP hasn't performed a procedure in a while, she feels a tad apprehensive prior to embarking upon one. Especially when it involves a scalpel and lidocaine and inflicting pain. But the beauty of having a few years under one's belt is that it all comes back to you when you need it. For better or for worse, even the inflicting pain becomes easier in one of those you've got to be cruel to be kind kind of ways.

And - gross though they may be - procedures are kind of fun. They are so much better to perform than to observe. In the case of an abscess, the results are immediate. The smell doesn't seem to bother newFNP so much when she is doing the cutting, expressing, irrigating and packing.

In fact, she wonders how her MAs are such tough asses in their assisting whereas newFNP has near syncopal episodes.

NewFNP is ready for more!

Again, for those struggling students out there, it's worth it. You'll be ready, too.

Money honey

2009-03-08T15:44:00.000-07:00

NewFNP has read article after article lamenting the primary care physician shortage. Often times, this is attributed to the high cost of medical school education. It's true - med school is expensive. It's true - physicians can make more money in specialty practice.

Nonetheless, these articles make newFNP a little pissy.

Jut hold up, mofos. There are nurse practitioners out there who are thrilled to be primary care providers. Nay, they chose to be NPs because they wanted to provide primary care. They wanted to prevent illness, they wanted to treat the whole person and not the disease. They wanted to be part of a health care team. They wanted to judiciously refer to specialty when the situation necessitated the referral.

And guess what? They have debt. They may even have a shitload of debt.

NewFNP's fancy NP school was seven semesters in length. The total tuition cost was in the neighborhood of $98,000. That's just the tuition. That's no rent, no books, no required health insurance, no specific-colored scrubs so as to identify students as students, no RN license. That's no red wine, no haircuts, no used book cafe coffee & treats with one's lady friends. And, at newFNP's school, there were a fair number of us who had other graduate degrees and their associated student loans. Thank heavens for the in-school deferment!

And thank heavens for loan repayment which mercifully wiped out quite a chunk of newFNP's debt, which now totals just a smidge over $60,000. Ah - $60,000 - it seems so reasonable.

So what is newFNP saying? She's simply saying: yo -- NPs! She feels your pain. You work hard, you take good care of your patients, you pay your six-figure student loan debt. Keep it up.

And for those of you in fancy and pricey NP schools, it's worth it. It's totally frigging worth it.

Hard times

2009-03-07T08:22:00.000-08:00

NewFNP noted recently that the economy is really hurting her patients.

It's worse now.

NewFNP referred three adult men and one pregnant women to food banks this week. Adult men in newFNP's clinic, as a rule, are a stoic bunch. They do not tell you that they are hurting or sad or worried. This week, newFNP saw desperation and fear in her patients' eyes - worries that they will not be able to feed their families, let alone pay their rent.

NewFNP hears on the news that lines for food assistance are longer, she hears the monthly unemployment numbers. She wonders if robbery is increasing as people become more desperate. Will the incidence of domestic violence increase?

During the Great Depression, unemployment rates were around 25%. In newFNP's county, they were almost 11% in January, a 3% increase since September. In newFNP's service area, unemployment is between 12-19%, depending on the zip code.

If you live in the hood, this is a depression. It is a depression. NewFNP's 401k is going through a recession but she has food on the table and gas in the car and not one but three paying jobs.

NewFNP is acutely aware between the haves (her) and the have-nots (her patients) as she sits in the exam rooms, listens to their stories and provide them with the best care she can given that the answer to their worries lies outside of the exam room walls.

On a lighter note, the aggressive-statement-maternity T-shirt shop does not appear to be struggling at all. NewFNP's non-fronting pregnant teen showed up to clinic this week wearing a shirt telling everyone to STOP HATIN. The graphic was, of course, a faded stop sign.

Oh give me a home

2009-02-24T21:10:00.000-08:00

If you are looking for a medical home, pal, newFNP's clinic ain't it.

Truly, in no way does newFNP's ramshackle community health clinic meet the criteria for a medical home. Access to one's regular provider* and a personal relationship with this person? No. Evidence based practice and support for providers? Nope. Expanded access to one's primary provider via phone or email? Sorry, no. Comprehensive care? Yeah - no. Reasonable wait times? Ha! That might be the most blatant 'no' of all.

Jesus, newFNP is a little bummed just thinking of all the ways in which her clinic sucks.

When newFNP thought of how she wanted to impact the well-being of the urban poor, she thought that she would help her patients to achieve health and thereby the ability to work given that they are - you know - not having MIs and diabetic retinopathy and teenage pregnancies. In her obviously skewed and possibly delusional pre-community health clinic mindset, access to healthcare led to health which led to well-being which led to productivity which led to the promise of financial stability and a brighter future for themselves and their families.

Ha! What the hell??!? Where has that wide-eyed girl gone? It's hard for newFNP to imagine herself being so idealistic.

There are times in which newFNP wonders exactly what good she is doing when her patients wait five hours to see her for a follow-up visit.

As newFNP has mentioned, her days have become busier since pulling back on her clinical hours. During this transition, newFNP has noticed a change. Her patients are waiting to see her despite the ridiculously long wait.

They come to clinic on newFNP's assigned days and wait. When they are assigned to other providers on a given day, they advocate for themselves and assert that they will wait rather than being cared for by someone whom they do not know. Of course, this is normal and the ideal situation - patients should not have to explain their diagnoses and personal situations over and over again. But newFNP just loves that these patients dig in their heels and say no.

They are medical homesteaders.

If newFNP was running the show, she would make one small change that might decrease the wait times for her loyal patients - and all of her other patients as well. She would schedule her patients on her actual schedule.

Seriously people, where is newFNP working? In a fucking MASH tent? Her clinic does not even schedule patients using newFNP's schedule template, yet newFNP sees 25+ patients every day she works. Does that make sense? If so, someone please drop some knowledge on newFNP because she would love to know.

----------

* The literature about medical homes all use physicians as the team leader. While newFNP appreciates the importance of physicians in the medical team, she does not believe that physicians need to be the primary care provider with whom patients have a relationship. NewFNP is not about 'us vs. them' but rather believes that there is room at the table for everyone. As the old saying goes, there is no "bite me" in teamwork. Or something like that.

On the OB front

2009-02-18T10:16:00.001-08:00

NewFNP's practice includes routine, low-risk office obstetrics. In some ways, it's a really nice practice - moms, babies - what's not to like??

Unlike other offices, newFNP's clinic does not have on-site ultrasound. Nor does her site have a family practice MD, an OB/GYN or a certified nurse midwife. Therefore, when newFNP runs up against a concerning finding, she has a few options. She can call the family practice MD at another site, she can consult with Dr. Dual-Ivy-League-Degrees who has some ER OB experience, she can page an attending OB at a nearby hospital or she can call BostonCNM for a telephone consult.

NewFNP wasn't expecting anything unusual with her 37-week primip yesterday. Sure, she was wearing a t-shirt with the phrase "OTHER BITCHES JUST FRONT" emblazoned across her chest in red 200-point font, but other than that, nothing out of the ordinary.

(As an aside, what does that even mean? Does it mean that she is a bitch, but that she in no way fronts? And if she is 100% not fronting, to what does that even refer? NewFNP is very confused.)

As newFNP starting asking her routine prenatal care questions, it came to light that her patient had been seen in the ER for preterm labor a mere six days before. Of course, she did not go to the ER where she is registered nor did she bring paperwork detailing the visit. According to her, she did not receive medications to stop the contractions, she had a normal NST, was observed overnight and then released. She had her paperwork at home, she assured newFNP, and would bring it to her next office visit.

NewFNP proceeded with the exam and was startled when she auscultated distinctly irregular fetal heart tones.

"Why they sound like that," her patient asked. "They was like that in the hospital too."

"What did the doctor say," asked newFNP.

"I dunno. He said it's normal I think," she replied.

Great. Sure, it can be normal. It can be a totally benign finding. Her 24-week level II ultrasound was normal in every way. But a repeat ultrasound or a fetal echocardiogram would provide newFNP with the reassurance she so sorely lacked at that moment.

NewFNP filled out the referral form for a perinatology consult and a repeat ultrasound.

When it comes to prenatal care, newFNP does not front. Whatever that means.

You shouldn't have!

2009-02-14T15:44:00.000-08:00

NewFNP isn't one to buy gifts off the street. Maybe in Milan or Oaxaca, but not so much in her clinic's urban area. However, judging by the amount of temporary vendors that pop up around the holidays - real or created - the urban stuffed animal street gift economy isn't suffering too much.

In fact, there are all manners of crappy gifts to be purchased streetside! NewFNP's interest in the street gifts was piqued when she noticed a trend, some may say disturbing, several years ago around Mother's Day. The hot ticket item that year was a ceramic swan in one's choice of ladylike pastels with a faux flower arrangement sprouting from the swan's hollow back.

No swans for Valentine's Day 2009. No sir. Of course, there are many options for Winnie the Pooh stuffed animals - small and large and extra large - wrapped in clear cellophane. There are carnations and roses and mini balloons. All of these things are available, sure, but are they really special? Is the mini Pooh with carnation combo really going to say "I love you" and possibly lead to mind-blowing amour on this potentially amour-filled day?

Or is a four-foot tall mirror in the shape of Tinkerbell going to nail it? Because if it is, newFNP knows where to score one.

Now, it might be said that newFNP's tastes tend toward the finer things and often exceed her budget. Her current obsession is the Bertoia bird chair (and ottoman) and the Tiffany & Co. platinum and diamond anchor pendant.

Alas, newFNP is not holding her breath.

Happy V.D. everybody!

Damned if you do

2009-02-11T19:49:00.000-08:00

NewFNP feels pretty confident about her diabetes management, her hypertensive skills, her strep throats and all the day to day family practice stuff.

But where newFNP gets a little tripped up is with the more uncommon diagnoses, such as Myasthenia Gravis, a pretty horrible autoimmune disorder in which your body creates antibodies that block its acetylcholine receptors, thus causing muscle weakness. A gross oversimplification, but it's late and newFNP needs to get out her physiology book to really explain this any better. End result is weakness because bodies need acetylcholine for muscle contraction.

Anyway, some people have ptosis - or weakness causing eyelid droop. Others have generalized weakness which frequently causes weakness and fatigue with chewing (a bulbar symptom), neck weakness that can lead to head droop and limb weakness. Still others have respiratory muscle weakness which can necessitate intubation. Not so fun.

NewFNP's patient has the generalized, bulbar weakness kind of myasthenia. She had a thymectomy about a year ago. It didn't help too much. She saw her neurologist a few weeks ago and was told to increase her aceylcholinesterase inhibitor - Mestinon - as well as her immunomodulator - prednisone. She is taking 8-10 tabs of Mestinon daily, as well as 8-12 tabs of prednisone 10mg - a hefty dose indeed. And her jaw continues to fatigue with chewing.

Because she was worried about her nutrition, she supplemented her diet with Ensure. Five to six Ensures a day for the past month, in fact. According to the Ensure website, each Ensure has 350 calories and 22g of sugar. And because everyone needs a little treat every now and then, she had been indulging in QID mini-doughnuts for about a week or so.

Anyone who has ever taken prednisone in the past knows that it can make you hungry, even ravenous. It can also in and of itself tip a heavy prednisone user into steroid-induced diabetes. Combine that with 1750 kcal/day in Ensure alone and you end up with a random glucose of 236 when you present to your well woman exam.

Frankly, newFNP was surprised that her sugar wasn't higher. Twice normal is so pedestrian in her clinic!

So then what do you do if you are newFNP? NewFNP cannot just take the patient off of her prednisone and start her on something else - that is neurology's purview. She can, and did, encourage her patient to chill out on the Ensure and doughnuts, to call her neurologist and let him know that her sugar is high, and to start taking Metformin.

Did newFNP mention that this patient is also depressed and was previously abused by her partner? Then she was diagnosed with myasthenia and had a thymectomy. And now she has diabetes.

The whole situation sucks.

It's the economy, stupid!

2009-02-01T13:25:00.000-08:00

Beginning a few months ago, newFNP noticed a disheartening trend. Many more of her patients - young, generally healthy patients - were coming with in complaints of things like dizziness, tingling in the arms and fingers, headache and diffuse muscle pain or, as a colleague likes to call it - total body dolor. NewFNP recognizes these symptoms as depressed mood. As newFNP is not a fan of the don't ask, don't tell policy in regards to a few things, including the medical history, she attempts to suss out the true cause of these symptoms. Her patients appear relieved that someone is actually asking them about the quality of their lives. Generally, they had experienced months of financial stress including food insecurity, home loss or inability to pay rent and zero prospects for imminent improvement.

When newFNP asks the questions about life stress, the question is often answered in a deluge of tears, seemingly pent up for all these months - perhaps trying to keep a strong face in front of the kids or family but unburdened in the small exam room.

Do these people need medical care, per se? No. What they need are jobs. It makes newFNP wonder about how bad things really were in the countries from where her patients came. They must have been awful to risk moving illegally to the US, to move to impoverished areas where their children often flounder - for a variety of reasons - in school or are introduced to gangs and to where supply greatly exceeds demand for unskilled laborers.

NewFNP did not go into healthcare to make the big bucks. But the truth is, she's OK financially. The only change in newFNP's life is that her clinical hours are busier than ever before and her 401k balance is dismal. What a relief that newFNP has decades of work ahead of her to recoup those losses! Decades of work. Fuck.

Anyway, newFNP supposes the real question is: what has this multi-multi-multi-billion dollar bailout done for the average middle-class person, the working class, the poor? NewFNP knows that AIG executives are doing fine, but her patients aren't and neither are many families across the country. We need a TARP for real people, a new New Deal. How about more student loan debt relief for teachers, nurses, physicians? How about actually giving money to taxpayers to pay they mortgages and student loans to the banks, who will then not have to ask for a bailout? How about putting a TARP over impoverished communities to bring better options for disenfranchised youth? To parents who want to work?

And now the Republicans don't want to pass the current stimulus package because there is, among other things, money for contraception?? What the fuck? People who can control their fertility tend to be more productive. People who work in clinics where contraception is a part of care earn money and pay taxes and mortgages and credit card bills.

NewFNP swears to God, enough is enough.

A new beginning

2009-01-20T22:44:00.000-08:00

Should today not have been a national holiday? Should we as a nation not rest for one day every four years to honor ourselves and our President?

NewFNP did pause today. She sat on the floor of the standing room only waiting room with a precocious five-year old African-American patient in her lap, her five-year old scrawny arms draped around newFNP's neck so that she and newFNP were watching the oath of office cheek to cheek.

"Do you know what today is?" newFNP asked this little girl, M as Vice President Biden exited the podium.

"No - what?" M replied.

"Today is a very special day. We are getting a new president - our first black president," newFNP told her.

"Obama?!?" she exclaimed, wide-eyed, although she pronounced his name Obommer. "I like Obommer!"

"So do I," newFNP said, giving M a big squeeze. "So do I."

Make it a double

2009-01-19T13:31:00.000-08:00

It is no surprise to newFNP that STDs are on the rise. Hell - in newFNP's clinic alone, she had several cases this week! Gonorrhea, check. Chlamydia, check. And repeat.

NewFNP's approach to disclosure of STDs is straightforward. It is generally something along the lines of: newFNP called you in today because your test results came back positive for chlamydia. NewFNP then pauses so as to gauge the individual patient's response. Some people are very nonchalant when they hear the news as though it was only a matter of time. Some people are angry. Still others are shocked.

Then there are responses such as this: But she told me that she was a virgin.

Well, maybe she wasn't. Maybe you were infected asymptomatically and here we are finding out right now. NewFNP doesn't spend a hell of a lot of time conducting an epidemiological survey. She treats her patient and, for chlamydia, she dispenses treatment to take to the patient's partner(s).

NewFNP brought her patient some water, his Azithromycin, as well as his partner's treatment dose. He took his medicine, set down the cup and tapped the partner's bottle.

"Uh, can I get two of these?" he asked sheepishly.

Sure buddy. Two partner treatment doses it is. Trying to blame it on the ex-virgin. Indeed!

Oh-ooh say IUD!

2009-01-08T20:02:00.000-08:00

It has been a long time since newFNP donned her protective gown and suited up for the old IUD insertion. So when her awesome MA told her that her G2P2 with 2 c-sections was in for a placement, newFNP was a little nervous. A nullip cervix after all these months of an IUD insertion-free existence?

"Not to worry, newFNP," her MA said," she's menstruating." And it's day two and it is a-flowin!

So newFNP got her patient prepped in the all-revered lithotomy position, placed the speculum, swabbed the moderate blood to better visualize her work place, and placed the tenaculum at ten and two o'clock. Click! Things were moving along super smoothly as newFNP quite easily sounded her patient's uterus to a respectable 9cm.

As newFNP was adjusting her vadge light to confirm that 9cm was in fact the magic number, a very, very unfortunate event occurred.

During the light adjustment, newFNP made the rookie mistake of not having one hand on the speculum. You see, newFNP's clinic does not have the fancy light-equipped specula. It has the old school cumbersome swan-necked style lights. One hand on the sound, another on the light and a setback occurred. It was just a seconds-long oversight that led to a size-medium bloody speculum to fly out of this lady's lady business, only to be caught by the still-in-place tenaculum.

Shit!!

NewFNP quickly and blindly removed the uterine sound as her sympathetic nervous system did an auto-reboot. She then paused for a millisecond to control her blood pressure as her patient and MA laughed the experience off. Thank God newFNP had done this patient's entire prenatal care course as well as her post-partum and well-baby care, and was known to her patient as not being a total frigging schmuck of a provider.

NewFNP replaced the speculum with the tenaculum still in place, a feat not so easily accomplished - you'll just have to trust newFNP on this one. She then pulled her other MA into the room for another hand to assist with speculum position maintenance throughout the remainder of the procedure which was as seamless as could be.

Perhaps newFNP should dig up her old chemistry goggles for her future IUD placements.

Thirty five

2009-01-06T19:11:00.000-08:00

NewFNP asked for it.

She wanted to go part time to save her sanity and now her clinic days are jam packed. Her days are busier than they ever were before. It is nuts. But newFNP is pretty cool with it.

She's even cool with her depressed patients who can present a true challenge during busy clinic days.

NewFNP must confess that it makes her a little frustrated and causes her to climb on her soapbox when she sees obvious somatic complaints and notes of 'depressed affect' time and time again in patients' charts yet no one steps up to the plate to frigging ask about it.

Sure, it may feel as though there is not a lot that one person in a busy health clinic which lacks mental health staffing may do to help that patient. And sometimes it's absolutely true that providers are just too stressed themselves to take on a depression visit. But we can't be so stressed that we shelf it to the next visit every time. That is just shrugging off the job and leaving sad, often ineffective and desperate patients in the same hole. And it is not true that we can do nothing. True, newFNP is no counselor, but the act of listening is powerful and making it okay for someone to cry, to disclose a crushingly painful secret, to release some bottled up hurt is therapeutic indeed.

NewFNP has been doing a lot of thinking about what kind of provider she is and what kind she wants to be since she has decreased her clinical hours to part time. It is so obvious that a smile and handshake is a warm way to start a clinic visit, but newFNP can't honestly say that she was providing that regularly in her darkest hours of full-time employment. She cringed as she read the NYT health blog and saw her bad behaviors in black and white. Ouch. She regained that warmth with her switch to part-time.

And while she is pretty crappy at orthopedic issues, newFNP is damn good at assessing for depression and she does not want to be the provider who ignores it. In fact, newFNP has found a new sense of purpose and satisfaction in seeing her depressed patients improve. The change can be so dramatic - what a joy to see that in someone. NewFNP has diabetic patients, on the other hand, whose A1Cs have hardly improved since being in her care. That is not so joyous.

Thirty-five patients today. And yet, newFNP is happy.

Weird.

Bust a capful

2008-12-21T15:41:00.000-08:00

It is not so often that newFNP has one of those "I've never heard that before" moments. And perhaps a vaginal exam is not the preferable circumstance in which to experience said moment.

NewFNP's patient was gravely concerned that her purportedly well endowed partner had somehow maneuvered her IUD out of position and that she was, therefore, pregnant. NewFNP had already seen the negative pregnancy test in the chart, delivered the result to the patient and offered to do a quick check to reassure her patient that the IUD was, in fact, intrauterine in location.

Although she consented to the exam, newFNP's patient specifically requested the use of a small speculum, which seems rather ironic given the reason for her aforementioned concern.

"A small speculum?" questioned newFNP.

"Yes," she replied, "because I use a capful." The way in which she casually said this assumed that newFNP was in the know regarding the significance of a capful, as though the use of a capful was a secret shared amongst women across the land.

"A capful?" newFNP inquired.

"Yeah, you know, a capful of vinegar," she explained.

NewFNP puzzled expression must have clued her patient in that she was not at all following.

"To keep it tight," she explained, "I put a capful of vinegar in my bathwater and that keeps you tight."

Does it now?

Vinegar. To dye easter eggs? Yes. To clean one's linoleum? Sure. To freshen one's coffee pot after a year of French Roast brewing? OK. But to keep a vagina tight? NewFNP is quite sure that Heloise would not offer that as a hint for non-food-based vinegar use.

NewFNP recommended Kegels, confirmed the IUD placement, reassured her patient of both her non-pregnant and actively contracepting status, and went on her vinegar free way.

Sticks and Stones

2008-12-18T21:47:00.000-08:00

NewFNP's clinic is breaking an unspoken mid-to-late December rule: keep it slow. Get out to the dollar store for some inexpensive winter-wear or to the champurrado vendor for some must-be-an-acquired-taste thick, greasy, masa-based hot chocolate but let newFNP have some holiday peace.

But no! NewFNP's productivity is through the frigging roof! She is averaging 30 patients per day and she has a student to boot.

A sub-par student.

There are some students who are great, like her NP student who attends newFNP's alma mater, like her PA student who was a former army medic and saved newFNP's ass as she incised and drained the biggest ass abscess she has ever seen.

Her current student is not good. She's not good. And she called newFNP "sweetie." Not once, but twice in the few weeks she has been there. NewFNP hates that kind of shit. She's no sweetie, mother-effers. And she is not B.F.F. with this young woman. However, newFNP has been so damned busy that she hasn't had the opportunity to nip that shit in the bud.

Sweetie?!?!! Ugh. It's repulsive.

12/21/08 update: In her defense, newFNP's student definitely does not think that she knows everything and she writes everything down. But her history taking and her SOAP notes are not so good and newFNP is a stickler for a good history and note - it makes everyone's life easier as patients come back for subsequent care. And then there is the issue of the 'sweetie' thing - is she taking her rotation seriously or is she looking to ingratiate herself? In newFNP's eyes, the easiest way to a fond feeling is a great performance.

Violence

2008-12-12T11:02:00.000-08:00

NewFNP regularly screens her patients for intimate partner violence (IPV). It's just one question, usually either "Do you feel safe at home?" or the not so nuanced "Does your partner abuse you?" It is a hard question to ask, but it becomes less hard the more you ask it and more hard when the answer is yes.

When the answer is yes and you work in a super ridiculous community health center, your day will be sub-par but likely nowhere near as crappy a day as the days leading up to a patient's disclosure that the are abused by their partner.

NewFNP's responses have been varied - she has sat with a patient while the patient called a local hotline, she has referred a patient to our fledgling medical-legal partnership, she has called the police.

But yesterday, a patient for whom the answer has been 'no' came in and disclosed that, all this time, the answer has in fact been 'yes.' At some point, this woman had the wherewithal to obtain a restraining order. This may have been when the abuse extended beyond her and to her oldest child.

Like many women, she wanted her partner to change. She wanted the abuse to stop, but she didn't necessarily want the entire relationship to stop. Like many women, she was afraid of losing her children - a fear heightened by her partner telling her that this was, in fact, what would happen and by her complete detachment from the legal system.

In some ways, this was an easy decision. Children are at risk, he violated a restraining order. NewFNP dialed the police. Unfortunately, he had left the house by the time they arrived.

When newFNP was in public health school, she visited a women's prison as a part of a class on family and sexual violence. It was a life-changing experience. In that group of women - convicted murderers - there were PTA moms and biker ladies. There was a woman who killed the man who got her daughter strung out on drugs and abused her. There was the woman who, after a brutal beating, killed her husband while he slept because he had been threatening to kill her and she knew that he wasn't kidding. Mostly these women were serving life sentences.

There are more aspects to this crime - on the batterer's side and the abused partner's side - than newFNP knows. Issues of power, of fear, of control, of rage, of money and poverty, of fucked up childhoods, of desperation, of gender inequality, of protecting what is valuable to you.

But these women shouldn't be locked away for life and newFNP's patient should never be in a position so desperate that homicide seems the only solution.

So ask. Just ask. As a provider, you might not have all the answers, but you are sure as hell equipped to find them out for a patient who might be caught between the bat and the belt. Or the gun.

This little piggy stayed the hell home!

2008-12-01T19:59:00.000-08:00

It's getting to be the holiday season and newFNP is sure that, like herself, there are many ladies who would like to get spiffed up for the festivities.

In order to be spiff and shiny, newFNP ordered herself some Kama Ayurveda Miraculous Beauty Fluid (an ayurvedic treasure) and some Lippman Collection Bitches Brew nail lacquer. Highlights aside, newFNP is a practitioner of DIY beauty. And though newFNP is loyal to her Retin-A for its utilitarian anti-aging/anti-acne benefits, she is a big lover of the rich, luscious facial serum.

You see, newFNP wants to look pretty pretty, but she does not want to spend tons of dough on comedone extractions and she does not want to go to the nail salon. And why? For one, in the world of beauty treatments, isn't a mani-pedi a bit of a rip off? Especially a manicure - if you are washing your hands all damned day, that $20 mani is shot to hell by patient number 7. For two, newFNP is super ticklish. For others, a pedicure is an exercise in relaxation. For newFNP, it's something that the CIA used to ban.

But even more importantly, newFNP is simply fearful of having toenail fungus. When she is 70 years old and her eyes are so bad that she can no longer see her long lady toes, fine. Toenail fungus it is. But newFNP is not giving up just yet.

NewFNP sees a lot of funky feet at work. She overcame her hesitation of peering for areas of maceration between moist toes, freed of their sweaty poly-blend socks and work shoes. She regularly assesses the dorsalis pedis pulses and is only mildly skeeved by the moist warmth of foot flesh.

And everyone has onychomycosis. The odds of finding a full set of normal toenails is somewhere in the ballpark of the odds of winning the Powerball.

Furthermore, newFNP remains scarred by her experience as a young public health professional when an epidemic of cutaneous tuberculosis was traced to a local nail salon and their recirculated water bowls. Not good. Not pretty. Not healthy.

So for this holiday season, newFNP recommends stocking up on your own favorite beauty treatment and some DIY nail care supplies - scented oil, hot water, a basin, some orange sticks, cuticle trimmers if you're into that sort of thing, a nail buff and nail lacquer.

Keep those little piggies fungus and TB free!