Broken safety net

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.

Booze Clues

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

She hasn't seen much improvement.

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

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

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

And he still doesn't have insurance.

There's an app for that

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

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

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

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

Nonetheless, they are wrong.

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

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

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

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

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

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

No. Just no.

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.

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

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.  

Five-0

Oh my God, did newFNP ever create one hell of a ruckus at clinic yesterday.

Being a mandated reporter - while important - can be difficult.  Say, for example, when a fourteen year old girl who has run away from home several times and drinks to the point of blacking out and is in newFNP's clinic for a pregnancy test tells newFNP that she doesn't feel safe at home.  And when she says that she is scared of her dad who is, by the way, sitting in the waiting room.  And that she is not scared of him because he is upset with all of her aforementioned behaviors.  And when she finally says that he sexually abuses her.  This four sentence synapsis, by the way, took 40 minutes of listening, questioning, waiting, etc.

So newFNP did what she is supposed to to.  She reported her suspicion for abuse to the local department of children's services who instructed her to call the police.  This is how two, then four, then five, and then seven police officers showed up at newFNP's clinic yesterday.  

If anyone was ever looking for a man in uniform, yesterday was the day to find one.   NewFNP, however, is not in the market.

NewFNP doesn't know if this girl has been abused or if this girl is just incredibly fucked up. Something is not right in her life or she wouldn't be involved in all of the risky behavior she is currently exploring.  It isn't really for newFNP to determine this though - that is for the detectives and the social workers.  

At the end of the day, newFNP cut out 15 minutes early, thinking to herself, "T.G.I. motherfucking F."

Keeping it new after all these years

Oh, how newFNP fucked herself by not immediately saying "no way, Jose" to her lorazepam seeking patient.  Blog commentors, newFNP hears you and acknowledges just how correct you all were.  Just when newFNP begins to think that she is no longer so new, something like this happens and newFNP realizes that new has a shitload to do with context.

Of course she came back and of course she wanted more of the sweet, sweet Ativan.  This time, newFNP really did need a prn dose to make it through the encounter.  Instead, she had to rely on her endogenous adrenalin.

Since she had last seen her, newFNP reviewed this patient's former med records which did not elicit the etiology of either the anxiety or the lorazepam prescription.  When newFNP let her patient know this, her patient found this to be an unacceptable obstacle and demanded more pills.  

NewFNP said no.

The encounter was one hundred shades of crazy, but involved soap opera-worthy acting, crying, laughing, the patient telling newFNP that the only reason she returned was that she felt like newFNP treated her with respect during the initial encounter (?!?!) and that she wanted to give newFNP a second chance.  Thanks.  Thanks a million, hon.

NewFNP still doesn't know if she handled this situation correctly, but she does know that if this woman does have a genuine anxiety disorder, Ativan is likely not the optimal choice for primary, long-term treatment and newFNP is not the person to decide what is.  NewFNP would just like you all to imagine what the response was to her offer to complete the psychiatry and counseling referrals.  Good fucking times, my friends.  

NewFNP was mercifully absent from today's all-staff meeting, but her spies expeditiously let her know that the CEO had received some complaints from board members about employees - apparently front desk staff - not treating them well.  Being an FQHC, a percentage of our board members are also our clients. While they say that we are not supposed to treat them any differently, that is a big fat lie.  The take-home message was that we are all supposed to ramp up our customer service.

NewFNP worries that patients like her lorazepam-seeking patient will complain.  She does not want to work in fear of patients who want something that she would be ill-advised to provide. She knows that while some patients are uniformly pleased with her, others are not always satisfied with her service.  The clinic is really not set up for provide great customer service and some of the patients really expect more that newFNP or her colleagues can reasonably provide.  

What to do, what to do.

Take that, newFNP!

NewFNP's clinic so rarely prescribes scheduled drugs that newFNP always feels a little hesitant to write for them.  Of course, there are exceptions to this, but these exceptions tend to occur in established patients with acute pain or anxiety or what-have-you.

They do not tend to occur with new walk-in patients who are at their third clinic in six months, who slur their speech and who disclose that they have been on SSI and have never worked due to asthma and back pain and knee pain and arthritis.  And who need Trazadone and Lorazepam to sleep every night.

Now, newFNP is sympathetic to the fact that people have and need treatment for pain and anxiety.  NewFNP is aware that people who are dependent on narcotics often need more narcotics to control their pain.  But newFNP's clinic is a) not a pain management clinic and b) situated in a crappy neighborhood with enough of a drug problem.  

And this patient was, frankly, just full of red flags.

So newFNP decided that she would refill this patient's lorazepam - it's not oxycontin after all - but that she would only give her 10 tablets while she awaited the medical records from her former provider.  Ditto the Trazadone.

Fucking hell, did the encounter ever go to the dogs!  NewFNP, apparently, had offended this patient by telling her that she needed to see her voluminous medical record before being able to continue her medical excuse for SSI and that 10 lorazepam was unacceptably stingy.  She was quite clear in her dissatisfaction.  Her exact words to newFNP were, "I need 10 lorazepams just to deal with people like you!"  It was a refreshingly honest statement.  She then informed newFNP that she will be no longer seeking care at newFNP's urban community health clinic, or more specifically and pointedly, with newFNP.

NewFNP breathed  sigh of relief. 

NewFNP probably could have handled this encounter better, but so could have newFNP's patient.  Like, for instance, slurring during the encounter generally does not bode well when one is seeking anxiolytics ad libitum.  

In retrospect, newFNP is sure that she had judgment in her voice when she told her patient about not freely authorizing SSI and med refills.  She feels badly about this and, with the next patient, she will choose her words more carefully.  But perhaps this woman has been screwing over the system.  NewFNP doesn't know and this patient just didn't seem to warrant the benefit of the doubt today.  

Feeling uncomfortable with the secure prescription pad in hand is not a sensation newFNP likes to experience.  Would newFNP have killed this woman if she write her for 20 or 30 lorazepam?  Doubtful.  Would the encounter have been more pleasant for the both of us?  Certainly.  

But newFNP had to do what she felt was right.  

Um, excuse me, but screw you.

Oh, how the tide changes from one day to the next.  Yesterday, newFNP was busy as hell, yet she didn't feel as though she had been crushed by a wooly mammoth when she returned home. In fact, as readers may recall, she actually felt wonderful.

Today, not so much.

Yes, it was busy.  That is the only similarity.  Busy, busy, busy with uncontrolled diabetics, physicals and a slough of other utterly non-interesting cases.  And busy with an infuriatingly frustrating all-staff meeting-slash-clusterfuck at the end of the day.  

It started out innocently enough.  Introductions, welcome new staff, blah blah blah.  Then newFNP's CEO moved on to the very touchy subject of providing decent care.  

In newFNP's clinic, there is no such thing as patient flow.  We do not have EMR; there are no reminder cards that it is time for your pap or mammogram or cholesterol screening.  Patients come in waves - charts overwhelm the hard plastic bins in which they are placed while providers attempt to make it through visits.  There is no urgent care clinic, nor are there hours set aside for urgent care.  Walk-ins are folded into the schedule along with appointed patients. Sometimes appointments are cancelled when the front-desk floodgate is so widely opened that the walk-in deluge overwhelms capacity.  Some providers see the expected amount of patients - about 25 per day.  Others see far fewer.

These are a few of the issues in newFNP's clinic.  Is it any wonder that we miss screening tests, the topic that opened this Pandora's Box? Theoretically, all it takes for a provider to miss something is too little time or too little motivation.  At times, newFNP is sure that even the best provider has been overworked or lazy or distracted.

So what does newFNP's clinic want?  Do they want thorough care or do they want fast care?  Do they want urgent care or do they want primary care?  Because they just cannot have both in the "system" currently in place.  

And then to top it off, newFNP had her first real taste of subtle NP-bashing while chatting about these issues with three of the physicians and the CEO after the meeting.

"Really," the new doctor said, "I'm the only doctor in C. [her clinical site in a nearby neighborhood]." Directing her eyes toward the two other physicians, she continued, "I think we should get together and talk about these issues."  

"Get together as doctors or get together as providers?" newFNP asked.  

"As providers, if mid-levels are interested.  I just don't see a lot of mid-level interest in these systems issues in C.," she responded.  

Yeah, asshole, mid-levels are interested.  NewFNP has been quite vocal about this for the past two and a half years.  She has met with the CEO.  She has talked to the CMO. She has discussed ideas with other providers.  She brings up systems issues in every provider meeting.  But unless management gets on board with these changes, newFNP may as well just spend her energy window shopping as Barneys because she is just as likely to have a closetful of Manolos and Marc Jacobs as she is to have these changes come to fruition. 

What is more maddening is that, up until this comment, newFNP always felt like she had a respected voice in this discussion.  It is fucking bad enough that the expectations for productivity are so high and that newFNP's patient flow is relentless.  But then to be devalued by a provider who has been working part-time at the clinic for all of three months?  NewFNP knows that there are physicians who just think that NPs and PAs are idiots, but aren't they smart enough to simply wait until the NP or PA leaves before they insult them?  And if you think that NPs and PAs are lame, why in the fuck would you work in community health where there are tons of them!

Unacceptable.

Healing.

It would have been easy for newFNP to just blow off the attitude of the almost thirteen-year old obese boy who begrudgingly attended his well child visit with his mom today.  Eyes steadfastly examining a single spot in the floor, his 213-pound frame turned away from his mom and from newFNP, he initially refused to respond to newFNP's questions or to his mom's exasperated pleas for the responses.

"You see, Doctora?" she lamented.  "This is how he always is."

NewFNP cares for this boy, his two younger brothers, his mom - who has diabetes - and his grandma who also has diabetes and who has had two strokes.  His mom cares for herself, her mother and her four children as best she can.  One older boy is on house arrest.  As newFNP flipped back to the last physical, she saw in her handwriting: father incarcerated.

NewFNP knew that this attitude was about that.  She asked the patient if his dad was still in jail - he is.  She asked him if that was why he was upset.  It was.  She asked the patient's mom to leave them alone, not quite certain how to broach the subject of the kid's attitude and his father's incarceration.  These topics are difficult for newFNP - she often feel like the emotional equivalent of a bull in a china shop when she has to discuss them.

True to that expectation, newFNP's start was rocky.  She asked her patient, whose emotional pain was weighing heavily in the room, to please look at her.  He refused.  She told him that it would mean a lot to her if he could just look at her.  He made a micro-movement toward her, decided against it and again faced the floor and told her no.  

NewFNP said, and in writing this she knows that it is harsh, "OK, so you just want to sit here and be a jerk?"  He said yes.  This affirmation opened the door for newFNP to ask him who has told him that he is a jerk.  

And the floodgates opened.  NewFNP is not sure what she would have done if they had not but it doesn't take a psychic to know that this kid has had a lot of negativity directed towards him.  'Jerk' may have been tame compared to other names he has been called. 

NewFNP spent the next twenty minutes listening to this devastated kid cry about how he misses his dad.  It was absolutely heartbreaking.  He doesn't want to go to school because his dad used to take him.  He doesn't want to go to the park because he sees all the other kids with their dads.  When someone picks on him at home, no one is there to defend him like his dad used to.  He is about to turn thirteen and all he wants for his birthday is to visit his father in prison.  He is concerned that he will be deported and that he won't see him again.  His uncle is mean to him, tells him bad words and to "calm the fuck down."  His aunt yells at him.  His mom is frustrated with him.

NewFNP was, frankly, not sure what to do.  Obviously, this kid is at high risk for school failure, perhaps for criminal behavior given that his brother and father both modeled it for him.  NewFNP knows that he is also at high risk for diabetes, that he already has fatty liver infiltration and she assumes that part of this overeating has an emotional component.  She made an executive decision to blow off the medical concerns for today - at least in part - and to focus more on his emotional decompensation.

She told him that he has already seen too much and suffered too much for his young life, acknowledged that life has dealt him an unfair hand, allowed him to grieve his loss and his loneliness.  She talked to him about his potential, about making good decisions and about how he is loved.  She told him that she saw a sweet person inside who wanted love and caretaking.  

She just let him cry and tell his story as, in the world according to newFNP, telling one's story is an important therapeutic process.  

At the end of the visit, newFNP listened to the kid's heart.  She let him listen to it - it was the first time he smiled during the visit.  She asked his permission to check his blood and ordered a cholesterol, a comprehensive metabolic panel and an A1c - just in case.  She told him that she would see him in two weeks.  The nutritionist referral will have to wait until then.

NewFNP left him in the room and spent a few minutes with his mom.  She asked her to tell him every day that she loved him.  She asked him to tell her bullying brother to lay the fuck off.  She told his mom that she was very worried about this sensitive and hurting boy.

NewFNP was e-mailing a pal from public health school to ask about mentoring programs for this kid when she heard him call her name.  She turned around and he gave her a big hug and thanked her.  

Even though newFNP thought how she was utterly powerless to change this kid's life during her encounter with him today, she simultaneously felt so grateful for the opportunity to say kind words to a troubled adolescent.  She needed that.  Clinic has been so overwhelmingly thankless lately that she had been questioning whether or not she could stay.  

Even though newFNP didn't do much medicine with this guy, she definitely did some nursing.  And some social work.  And it felt really, really good.

Ah ah ah - stop right there

NewFNP has been slacking because all that has been occurring in her clinic is drama, drama, drama. It is exhausting. Save the drama for you mama is right!

Anyway, clinical telenovelas aside, newFNP's clinic has instituted this "new" practice policy of addressing just one concern per visit. It's not revolutionary, it's just that some of us (read: newFNP) have a difficult time adhering to it.

In newFNP's clinic, it takes about 3 weeks to get an appointment so newFNP can understand why a patient may want to kill you for saying that they need to schedule yet another appointment, for which they must arrive on time and subsequently wait 30-90 minutes to get seen. Would it kill newFNP to look in your ear when you're truly there for your pap results? Unlikely. Will you assume that this willingness to overlook the rules extends to each and every clinical visit? Definitely. Honestly, someone else needs to be the bad guy. There needs to be a triage nurse or some type of signage up in every room letting patients know that it's 1 - not 3, not 5 - concern per visit. No, no signage. All of newFNP's patients ignore the 'turn your cell phone off' sign, as well as the 'shoes off if you're diabetic' sign. No, newFNP's appointment needs a triage nurse that pins the real concern down.

And for the love of all that is holy, what is newFNP to do when her 50 year old patient with normal lab results tells her that his lower back is hurting? Should she even begin to ask about it? Should she punch him in the gut and ask, "Any less pain in the back now?" Seriously, once newFNP hears a complaint, she feels a little compelled to address it. What if his prostate is the size of a Buick? What if he has the horrifyingly freaky cauda equina syndrome? NewFNP would assume that over the counter Tylenol, even extra-strength, wouldn't touch that motherfucker!

NewFNP printed an article from the current issue of Family Practice Management entitled "How to Manage the Difficult Patient." It's pretty helpful and reminds newFNP that, no matter what, she should not be another problem on the already exhaustive chief complaint list.

Hg free for you & me

At newFNP's clinic, Fridays are reserved for pediatrics and, more specifically, for well child checks. *Well* child. Physicals and vaccines. Sure, newFNP will treat your child's ezcema during the WCC. She, however, cannot solve your daughter's super-fucked up life in 15 minutes. NewFNP can generally survive one train-wreck on Fridays. But four? Well, four is just too damn many. Especially afternoon train wrecks. Isn't there some type of screening tool the front desk staff can utilize in order to schedule all of the emotionally exhaustive patients in the morning? Doubtful, given that newFNP continues to struggle with labels missing from a fair number of her charts.

NewFNP's first afternoon patient was a 15-year old girl, absoultely ridden with sour-puss attitude, who had missed school for a month because the pills she was taking for her abdominal pain made her sleepy. What was she taking? Lunesta? Oh, the attitude. NewFNP knows that she must have been somewhat like this girl oh-so-many years ago and it pained her to see that she may have been such an asshole. NewFNP generally likes teenagers, but she was considering advising this patient to go screw herself. NewFNP rose above the temptation, however. A smart move all in all.

Then newFNP had the walk-in depressed patient with the very chatty grandmother. Her patient was a very sweet young man and his grandmother was very concerned. However, newFNP does not need the anecdotes regarding the patient's anxious sister, grandma's 'nerves' and dad's relationship issues during the already tight walk-in schedule.

Then there were the sisters with the mercury exposure. Too much tilefish? Broken thermometer? Nope. In newFNP's mind, this is the epitome of a ghetto exposure story.

These sisters attended a baby shower in a house located next to a junk yard. Some kids were playing with a bottle filled with silver liquid that they found in the junk yard. Opened up the bottle and - voila! Millions of little silver balls! Please kids, please... don't play in junk yards. NewFNP doesn't even like to go to Ross, so there is no fucking way that she is going to a junk yard. Anyway, word got out that the house was subsequently quarantined as a result of the exposure so newFNP needed to evaluate the kids.

The only problem was that newFNP didn't learn about frigging mercury exposure in school. She just learned not to eat mackerel. So, off to the CDC website for some guidance. In short - assess for respiratory complications, draw their blood and do a urine, preferably a 24-hour urine but a spot urine will do in a pinch. Call the health department. Done, done and done.

Oh but wait, what do you do if one of the mercury kids had scooped up some of the pretty, shiny toxin and taken it to school, where she then threw it away? Well, then you call the haz-mat team and everyone gets an early summer vacation.

NewFNP thought that she was finished with the heavy metal when she received a call from our friendly neighborhood laboratory draw station. The attendant had the requisition forms from newFNP's patients, but apparently their mother and a whole other family was there to get their labs checked as well. NewFNP's patients truly do not know how the health care system works and newFNP spends an inordinate amount of time explaining things such as what it means to have refills on prescriptions and why patients need appointments. Now this poor lab worker was stuck doing the explaining as to why you can't just walk into a lab and order tests yourself.

Oh, community health. The hits just keep on comin!

NewFNP did, however, feel very proud of herself for acting as a public health practitioner today. Sure, all she did was call the toxics epidemiology department, but she sure felt good about doing it. It made newFNP realize how much providing individual health makes her miss public health. One day.... one day.

Is that a twinkie in your pocket?

It is a hard fact of practice that there will be a time in a clinician's life when he or she will be confronted with an erect penis. NewFNP is not talking about after work; she is referring to on-the-clock erections.

In newFNP's experience, these awkward moments tend to occur with teenage boys who will pitch a tent upon sensing a sideways glance at the penis. There appear to be two schools of thought regarding the acknowledgement this experience. School one says, "Hey, let's all normalize the exam erection for the patient and tell them not to be embarrassed - it happens all the time." School two says fuck that. Sure it's embarrassing for the patient and awkward for the provider, but saying "Oh, it appears that you have an erection. Don't worry, newFNP sees millions of erect penises every day!" might be mortifying. NewFNP belongs to school two. That is why she leaves the genital exam for last on her erection-prone male patients.

In general, newFNP really feels sorry for her male patients who have an itchy trigger penis. She knows that they know that they have an erection at an inappropriate time. She knows that they are uncomfortable and assumes that they might like to sink into a crack in the floor. As such, newFNP simply finishes her exam, states that everything appears normal (as long as everything does appear normal) and invites her patient to get dressed after she excuses herself. She returns to a fully-dressed and fully flaccid patient to conduct any education.

As newFNP stated, she generally feels sympathy for these guys. However, there is an exception to that rule.

NewFNP is, quite frankly, sick of men telling her how they have a girlfriend but have other partners and do not use condoms with any of them. In newFNP's mind, this is wrong on several levels - infidelity, potential exposure to communicable disease, being a slimy bastard. When newFNP's skeevy 32-year old patient told her how difficult it was to control himself when he had a few beers and started dancing with and kissing other women, she thought about rolling her eyes and calling him a prick, but she decided against that intervention. Instead, she educated about risk reduction, mutual monogamy and encouraged him to be a man of his word.

So imagine her suprise when, after being more judgmental than usual, newFNP's pervy patient had an erection during his exam. NewFNP's gag reflex was triggered. Should newFNP have done a gen-probe rather than a urine GC/CT? Who knows. She didn't, mostly because she had no desire to touch the man's genitals after assessing for testicular masses, of which there were none.

Keep it holstered, dude. NewFNP feels no sympathy for womanizing, dishonest, boner-having 32-year olds. Gross. Clearly he was not lying about being unable to control himself.

NewFNP needs hazard pay sometimes. Please, cough your TB in newFNP's direction but keep your erection out of her face. Ugh.

Don't be a fool - stay in school!

NewFNP loves school. She wishes that she could forever just go to school. The life of a student - a grad student that is - is one which suits newFNP to a T. Some classes, some studying/snacking/coffee at a local coffee house with her pals, some hitting the awesome 7-story gym provided to her by her educational institution, some thinking, contemplating, practicing, reading... you get the picture.

Now newFNP knows that high, middle and primary schools are not as much fun as grad school, yet they are probably more important because they are a platform, a springboard if you will, to bigger and better things.

Thus, newFNP's newest pet peeve: parents who are not teaching their kids to value school. It's always been an issue for newFNP, but this past week has been the worst. Take you kid to school, take their fucking TV out of their room if their grades are in the pooper and don't pull them out of school for 2 months to go visit relatives in another country. NewFNP just read an article in The New Yorker about parents pulling their kids out of an urban high school in Denver in order to take them to dry wall jobs. To newFNP, that is unconscionable.

Lest anyone think that newFNP was a child of privilege, let newFNP assure you that that is not the case. NewFNP's family simply taught newFNP's generation that we would be successful in education and life. The strategy worked.

NewFNP is not insensitive to the fact that people need to pay the rent. But here, in newFNP's frigging expensive city, if you don't want to live paycheck to paycheck, you had better get an education and a good job.

So go to frigging school!

MRSA! MRSA! MRSA!

NewFNP has had some tough patients this week.

There was the 80-year old with CHF and hepatic congestion. Do they make liver sudafed because we need to decongest that bad boy!? NewFNP is decongesting that old liver and treating the CHF with good old-fashioned furosemide, which should really improve her urinary incontinence. Sorry about that.

Then there was the lady who was adamant that newFNP had not refilled her Relpax last month. NewFNP remembers the conversation in which she said that she would refill it. NewFNP wrote in the chart that she refilled it, but did newFNP hand the medicine to the patient herself? No, she did not. That responsibility falls to our dispensary clerk, who is sweet yet lacks a certain something - let's call it IQ/ability to multi-task/grace under pressure. It is not out of the realm of possibility to think that newFNP's patient perhaps did not receive her medications. However, newFNP has to trust herself and her employees and, thus, did not refill the med. NewFNP's patient was practically homicidal. It was not an enjoyable experience. Yes, newFNP knows that you are not stupid. Of course, newFNP appreciates that you are not a liar. Yes, newFNP understands that you would like her to supervise every interaction that occurs between all staff members and patients of the clinic. Sadly, newFNP has 29 other patients to see. NewFNP apologized, of course, but our relationship is damaged.

NewFNP hasn't had too many patients get mad at her. It was a drag, but newFNP had to stick by her staff because there was no clear mistake. The documentation stated that the patient received the medication. Bummer.

In other news, apparently the power of the blog is beyond what newFNP imagined. After posting that she hadn't heard from clinic B, newFNP received an e-mail asking her to interview... this Thursday at 9AM. This e-mail came in one week after newFNP's e-mail went out. How about some advanced notice for schedule clearing purposes? We'll see. We'll see.

And finally, check out this article on slate.com about antibiotic resistance.
http://www.slate.com/id/2152118/
Not a day goes by during which newFNP does not chastise a patient about antibiotic misuse. Come on people! Get with the program!

What to do, what to do

As many of you know, newFNP has been experiencing distress at her place of employment as of late. This distress led newFNP to forward her CV to two of her public health type colleagues who are, as they say, connected.

And now newFNP has a job interview at the Cadillac of community health clinics.

Here is the conundrum. There is never a *good* time to change jobs. There are times that are worse than others. For example, newFNP has a three-week vacation planned in February. Is it a bad thing to say, "Oh, and BTW, I'm going to need to take February off. Problem with that?" NewFNP thinks that is not ideal. Secondly, newFNP let her CPR certification lapse. Fucking hell because now newFNP has to sit in that MF-ing course all over again. Double fucking hell because it looks flat out bad to let such a thing lapse when applying for new employment. Thirdly, newFNP's clinic just lost a provider - no big shock. This does, however, cause extra stress on the existing staff.

Finally, newFNP really likes and respects the MD with whom she works. NewFNP will need to excuse herself from work for a half-day to attend said interview. NewFNP wants to tell her MD, but doesn't want her MD to think she is a big ship-jumping a-hole. Ay ay ay. And newFNP is not even sure that she wants to leave her fucked up community health clinic for a more posh community health clinic. This posh clinic is at least 15 minutes further from newFNP's new apartment and, in newFNP's city, that could be a real problem.

NewFNP has about 10.5 hours to figure this all out.

You're fine, now go away

Frankly, having no insurance sucks.

NewFNP had a patient whom she began to treat for anemia last week when she entered our clinic with a heavy period and a hemoglobin of 7.2. For those not in the know, that qualifies as 'fucking anemic' as opposed to 'holy shit, is this patient ever anemic.' NewFNP's approach was three-fold:

1) iron supplementation (duh) and repeat hemoglobin in 48 hours
2) oral contraception (no provera available in the clinic)
3) CBC

Upon said patient's return, her hemoglobin had increased to 7.4, not an amount for which anyone will win any prizes but enough to calm any fears of imminent bleeding out. This is no faily tale, however as this lady's OCP was causing vomiting and a lot of it. NewFNP operates from a philosophy of avoiding insult to injury and, therefore, changed up homegirl's pills.

Alas, while the patient tolerated her new pills well, her menses was one tough customer and didn't feel the need to leave her the hell alone. She went to the ED and received 2 units of blood. Although newFNP did not see her in follow-up, she did see that her hemoglobin was a nice 11.8 the next week. Her period, however, was tenacious! It was not to be stopped by hormonal contraception alone. She was referred to an OB/GYN and received essentially no care.

She returned to newFNP's clinic the next day, clutching her head and crying in pain. She had been seen in the ED the night before, received no imaging and was discharged with a diagnosis of migraine. In the clinic, her right eye was deviating from its normal gaze. She was the most distressed patient newFNP has seen, excluding of course first rectal exams and male GU accidental erections. NewFNP called 911 and the friendly firemen took her to the hospital.

A quick phone call to the patient's home the next day revealed that she was, yet again, discharged with no imaging and told that she needed to see a neurologist. Yeah, no shit ass-crack. That's why newFNP sent her to the fucking hospital in the first place. How the fuck can we tell if the reason she has such heavy periods isn't from some underlying bleeding disorder that is causing her to also bleed in her brain if we don't do imaging?

When a 17-year old with anxiety comes into newFNP's clinic complaining of chest pain, she is likely to get the full cardiac work-up (read: an EKG and auscultation in all essential spots instead of just one or two). When a tyke with a sore throat comes in, newFNP checks him out as though he could have something aside from the 85% likelihood diagnosis of viral pharyngitis. NewFNP does not send every case to the ED. Apparently, that's a good thing given the crappy care they receive.

NewFNP knows that the EDs are overburdened with patients as well, but seriously, what the fuck?

Hold the mayo

There are days during which patients just break newFNP's heart.

Imagine having gone through a fetal loss, an ectopic with subsequent tubal scarring and years of infertility before finally meeting a reproductive endocrinologist who will work with you when you're uninsured. Imagine being evaluated for Clomid and preparing to start using it. Then imagine finding a breast lump. Then having a fine needle biopsy with a "bad" result. And then imagine the waiting between those results and your impending excisional biopsy, when you have nothing to do but think of how you're not pregnant and how maybe you have breast cancer just like the beautiful woman sitting next to you in the breast clinic when you had your needle biopsy.

And on top of all that crap you get a cold and end up in newFNP's care. Son of a bitch, right? That's just what you need!

NewFNP breaks the touch barrier a lot. She believes that a handshake or a simple pat on the back or the arm goes a long way in welcoming patients. NewFNP took this patient into her arms today as she sobbed.

So, yes, there are days when patients just break newFNP's heart. Of course, there are also days during which patients just bust newFNP's chops as well.

Today was a combo platter.

It's not you, it's me....

NewFNP has had some tough conversations in her day, ranging from "Well, I actually am not a real fan of purple angora mock turtlenecks but thanks for the thought" to "You have chlamydia" to "I really feel like this is not working out with us." Now she has had the "You have cancer" talk.

As with any break-up conversation newFNP has had, the build-up was worse than the event. NewFNP was surprised, quite frankly, at how unaffected the patient was upon hearing the news of her cervical cancer. Perhaps she didn't understand, perhaps she was shocked, perhaps just stoic. Her daughter, on the other hand, appeared to grasp the magnitude of the diagnosis and perhaps her mother's mortality.

In speaking with the woman and her daughter, newFNP asked again when the patient's last pap had been. Her daughter asked, "Two years ago, right?" Her mom replied that she had never had a pap and that the exam two years ago was a mammogram. This is a multiparrous woman - no pap ever. NewFNP is struck by the frequency of that experience in her patient population. She also is reminded of how important it can be to ask the same questions over and again, especially if your communication is compromised by language issues.

As newFNP has had time to reflect upon the initial appointment, she is struck again at how she initially doubted her eyes and her knowledge and how, upon receiving the result, she began to appreciate her abilities. As newFNP reflects upon the care uninsured people receive, she is struck by how flat out fucked they can be. NewFNP has awesome insurance at a very hoity-toity facility. She has a palpably and audibly crunchy knee that needs evaluation. She received her appointment the same day as her primary care physician generated the referral. NewFNP's patient has a big ole tumor in her va-jay-jay and our referral coordinator couldn't secure a colpo/biopsy appointment for her. She had to walk into a specified clinic, lab result in hand, and get medical attention.

Her biopsy was last week, as was her CT scan. NewFNP is awaiting the results, fearful of what they will bring.

Although it didn't feel good to tell this woman that she has cancer, it felt right. It felt respectful to deliver difficult news straightforwardly and compassionately, to answer questions and to be a support.

Now let's get those HPV vaccines rolled out and prevent all these abnormal paps, biopsies, cancers and deaths.

And the hits just keep on comin'

NewFNP has been on hiatus, largely although not entirely due to a lack of fun/interesting stories to share. Nonetheless, as newFNP indugles in a some moments of reflection here and there, she finds that there are some stories worth sharing.

In the on-going series of firsts, allow newFNP to share some of the new experiences she has had in the past two weeks:

-first patient passing out, becoming diaphoretic and having a BP of 68/42 and a HR of 40 during venipuncture.

-first patient with 8+ hours of uncontrolled epistaxis coupled with first experience of being unable to find 1:1000 epi and served with a side of being the only provider in the clinic.

-first realization that my 19-year old patient is engaged to and not the daughter of my 58-year old patient. Permit me an aside, s'il vous plait. Upon further questioning, this young woman disclosed that she and her partner had begun "dating" when she was an assumingly worldly 13-years old. Their son is three. What was her life like that a then 52-year old man was attractive to her? Where were her parents? Why did the man troll down that path of pedophilia? And why is the gentleman I know today, the same man who was screwing a child, so incredibly likeable?

-first suspected child abuse reporting call, only it wasn't suspected. Note: don't forget to ask what the child is hit with, ie. a belt, a hand, a shitty start to life.

-first time of blinking back tears due to feeling utterly overwhelmed, suprisingly not on the same day as the child abuse report.

-first time looking in an ear and seeing something resembling the aftermath of a roadside bomb. Shades of red and gray, jagged edges to a clearly blown TM. Tumor v. traumatic rupture of TM? Let's have the ED decide.

Oh, life. Is it too soon to ask for a raise?