Oh, did she go to Hopkins?

NewFNP was enjoying the lull experienced last week thanks to graduations and World Cup. It was all about 20-22 patients per day last week. Well, that lull is over. Thanks a lot, Mexico - way to get eliminated.

The patients are back, and quite a few of them are vexing newFNP. NewFNP must admit that she feels excessive frustration when her patients do not adhere to the regimen she prescribes. Yes, it's the patient's choice whether to go along with the plan or not. However, if the patient chooses not to get with the program, it is newFNP's hope that the patient will not continue to come to the clinic and complain of the same thing over and over again, ad nauseam.

NewFNP's 40-something year old depressed patient with a history of clearly unresolved childhood physical abuse and the full SIGECAPS spectrum reviewed her SSRI/counseling treatment plan with a cousin who advised her to just "work it out" on her own. NewFNP inquired, "Is your cousin a doctor?" Astoundingly, she's not. Nonetheless, blood is thicker than water, even when water wears the white coat. So, OK, Horatio Alger-ess, grab onto those bootstraps and start pulling.

You think you had a bad week?

OK, listen. There are many difficult situations which newFNP must control in the course of a work week. These include, but are not limited to, the following quotes from patients and/or clinical experiences from last week:

• 'I stopped taking my Benadryl because it makes my eyes hurt.'
• 'My cholesterol medicine makes my throat hurt.'
• 'My hernia [umbilical] is hurting and I didn't go to my ultrasound appointment, nor did I call to cancel or change the date.' This is a paraphrase. This same patient also told me that she felt "little balls" on her abdomen. Yeah, sister, that is called cellulite. Tummy cellulite. Now goodbye.
• 'All I eat are fruits and vegetables.' Hmmm.... 276 pounds and a glucose of 350, all from those dastardly fruits and vegetables? Perhaps newFNP is approaching diabetes care all wrong.
• Let's see, what else: fat kid, fat kid, fat kid, kid with possible ocular tumor, fat kid with hypertension, primagravida with a fetal ultrasound too devastating to describe, fat kid, hugely fat adult.... you get the picture.

But do you know what made last week a fucking nightmare? I'll tell you.

NewFNP has lost her palm pilot. The son of a bitch is gone, along with ePocrates, Kid-O-Meter, BMI Calculator, 10 year risk assessments, my hairdresser's phone number, my facialist's phone number and a plethora of other useful information. NewFNP has a new PDA on the way but misses her piece of crap Clie.

Sony Clie, wherever you are, newFNP loves you.

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.

A plea

Ladies, please - hear me out.

Now, newFNP knows that all members of the fairer sex will at some point be afflicted with nipple hair, or more specifically, peri-areolar hair. NewFNP is not of hirsute stock, yet even she has had to endure this hardship. But what makes this tragedy something one can easily overcome is a little something called tweezers, a not-so-new technology. NewFNP opts for Tweezerman, but she is sure that even Revlon makes a pair that would be suitable for boob tweezing. Especially when your nipple hair is coarse like a man's and two inches long like a certain recent patient in clinic. So, please, cut newFNP some breast exam slack and tweeze.

Disclaimer: newFNP considers herself 100% feminist and does feel some guilt regarding both this post and her aversion to whatever makes her female patients happy as far as breasts go. NewFNP will send a check off to NOW right away.

Right after she sharpens the edge of her tweezers.

Oh, to be wrong!

Normally, newFNP enjoys being correct. NewFNP likes good grades and completed NY Times crossword puzzles (only the Sunday magazine crossword, not the NYT crossword). At this relatively early stage of her career, newFNP also enjoys correct diagnoses. When she presumptively treats a strep throat while awaiting culture results, she feels selfishly relieved when the cultures are positive.

NewFNP, however, is not so pleased with her correct presumptive diagnosis in her sweet 68-year old patient. This woman's chief complaint was urinary incontinence, but she also noted a very foul vaginal discharge. Oh, and some vaginal bleeding. Not all the time, but vaginal bleeding nonetheless. The words "post-menopausal vaginal bleeding is cancer until proven otherwise" rang in newFNP's head as she was taking the history.

Other pertinent info:

• no sexual activity for many years
• last pap 2004 - patient assumes it was normal
• vaginal discharge progressively worsening over 6 months
• vaginal bleeding times 4 months - intermittent

It's newFNP's understanding that there are some vaginal infections that present themselves even before the patient is in the lithotomy position thanks to the ol' olfactory system. NewFNP had yet to experience such an infection until meeting this patient.

Although it feels insensitive to say it, newFNP had to choke down her gag reflex during the exam. The odor was reminiscent of abscess contents. The discharge was green and, man alive, was it ever copious! It was literally running out of the speculum as fast as newFNP could swab it.

Now, newFNP frequently wonders if cervical lesions will be visible to the naked eye. Ectropion, sure. But what about those purple lesions? Are they moles? Should I know this? Whenever newFNP sees something she is unclear on, she makes sure to get a nice sample of it for the pap. Well, what this lady had going on was so visible that newFNP had to look at it many times over to actually believe what she was seeing.

If memory serves correctly, the chart note read something like: Gray round lesion, approx 1.5 cm, rough surface, adjacent to cervix at 3:00. Friable.

The referral note states: Rule out gyn cancer. Pap pending.

The pap isn't pending. It was faxed to newFNP today. Squamous cell carcinoma. No BV, no trich, no gardnerella. No GC/CT. All of that discharge must have been necrotic tissue sloughing off.

In the next few days, newFNP will be, for the first time, telling a patient that she has cancer. In Spanish. In fucking Spanish.

It is horrible to be right sometimes. Yet, it does reinforce the adage that seeing enough normals will help you to recognize the abnormals. That, however, isn't enough consolation for newFNP right now.

What a feeling!

Apparently, newFNP's HR department has nothing better to do than to come up with new policies regarding professional attire. There were some expected no-no's, of course, such as a prohibition against shorts and half-shirts. Sorry, Beyonce, no job for you at newFNP's clinic!

There were, however, some unusual frowned upon fashion pronouncements. For instance, it is "inappropriate" to wear khakis or chinos. I'm sorry, but where is it appropriate to wear khakis if not to work? Also not making the cut were clogs, of all things. Sorry Dansko. You'll have to appeal to the Dutch because the community health clinic says you are inappropriate.

The most unusual fasion item to make the "no" list were... wait for it..... stirrup pants! Please, someone tell me, what is newFNP going to wear with her leg warmers, headband and off-the-shoulder sweatshirt? What's next? Outlawing Forenza oversized v-neck sweaters and Members Only jackets?

Char-que?

There are times throughout the day during which newFNP sees her patient and immediately senses a "what the fuck" coming on. What newFNP would like to do is gingerly tiptoe backwards out of the exam room, hoping that the patient never noticed that she was there.

Given the state of affairs of one patient today, newFNP could have probably succeeded in the aforementioned exit strategy.

Before continuing, can newFNP just make one more plea to prevent frigging Type 2 diabetes? Yes, yes, we can't save them all, but newFNP is sure as shit saving herself. And if a gaggle of patients want to set sail in the health boat with newFNP, they can hop on board. Ahoy!

Here is why "Develop Type 2 DM" is not on newFNP's to-do list.

A) Renal failure.
B) Proliferative retinopathy/blindness.
C) Peripheral neuropathy/amputation.

And if that weren't enough, newFNP has a new reason to add to her list: Charcot's Foot - a complication of neuropathy that leads to fractures of the bones without having experienced major trauma. Because of the neuropathy, the fracture isn't felt by the patient who continues to walk on the affected foot. This, in turn, leads to severe deformities, sometimes intractable ulceration and the potential for amputation.

If you haven't seen Charcot's Foot before, conjure images of Kathy Bates' character hobbling James Caan in "Misery." That is what Charcot's looks like. It's swollen, warmer than surrounding skin and looks like someone took a sledgehammer to it.

And if that wasn't incentive enough, just think of this: Charcot's Feet cannot wear cute shoes.

Parenting 101

A little about me. NewFNP is not a parent. However, newFNP knows crappy parenting when she is beaten over the head with it.

Take for instance the mother and daughter pregnancy test walk-ins this week. Mom in her late 30's, daughter in her late teens. Mom's test negative, daughter's test positive. Mom relieved yet concerned about having had two menstrual periods the previous month. Daughter devastated, crying, fallen, crushed.

Mom wrapped her arm around her daugher's shoulders and told newFNP that her daugher had been raped in February. NewFNP inquired as to post-sexual assault care. She had none. No health care, no police report. No menstrual period for two months. No knowledge of whether she had been infected with an STI. No counseling.

Mom repeated over and over to the daughter, "It's OK, it's OK." OK? Fourteen weeks pregnant as a result of a rape is OK? No, not OK. Pretty fucking far from OK.

After a 20-second series of "it's OKs," mom turned her attention back toward herself and inquired as to her irregular periods. NewFNP said something polite but dismissive in order to re-direct the conversation to the daughter. Mom played along, but would not be deterred from receiving the answer to her relatively pedestrian query. NewFNP encouraged her to follow-up with an appointment. What newFNP wanted to tell her was to drop it and to focus her attention on the needs of her re-traumatized daughter.

Is newFNP out of her tree or is there a time during which you let your needs fall aside in order to deal with a crisis? Isn't that part of being a parent? That's part of the reason why newFNP is sans child - still selfish, this newFNP! Still putting her needs first.

Speaking of, J. Crew has some cute frigging spring flats. Perfect with smart trousers for clinic-wear!

Wet to dry

It's not until one washes one's hand three trillion times per day that one truly appreciates the drying effects of water. It's Saharian in its drying capacity. However, one can certainly understand how a patient who is told that she needs a wet dressing in order to dry a seeping wound might raise an 80-year old eyebrow and toddle off to the pharmacy to buy some more minty-cream.

NewFNP was happy to take a look at her patient's wound yesterday. In fact, when newFNP was in her whirlwind med-surg rotation, she was somewhat of a wound guru. Well, folks, those days are long-fucking-gone. As newFNP unwrapped the homemade bandage and caught a whiff of the minty salve, she began to realize the extent to which one year of untreated wound festering can wreak havoc upon delicate ankle skin. What began as a "vein" that she scratched with her shoe turned into a large - let's say 5 inches in diameter - ulcer covered with thickened yellow necrotic tissue.

She has been using all matters of salves and creams for the past year, all leaving her unfulfilled and with a growing lesion. The scent of the cream she was rocking in clinic yesterday was reminiscent of kindergarten paste and she had applied it just as thickly as would a 5-year old. She told me, with utter contempt, that one doctor told her that she should just cover it with water and that it would heal. The tone in which she conveyed this story implied, "As if."

When newFNP prescribed the exact same treatment, she wrote the kindly old lady a prescription for sterile water and told her that she needed to use this "special water" to heal her wound over the course of the next year.

Special fairy water - that's what newFNP will say next time.

Body count

Hours worked: 8
Number of patient visits: 27
Number of complete physicals: 6
Number of IUD insertions newFNP did for the first-ever time: 1
Number of third-graders weighing in at greater than 100 pounds: 2

Number of weeks of vacation newFNP currently receives through her clinic: 2
Number of sick/personal days: 4 - total, not each.

Sure, newFNP understands that she earns approximately 10K under market because she works in community health. Sure, she is savvy enough to reason why she is forced to see so many patients day in and day out.

But what newFNP does not understand is why her clinic's management does not seem to address the concept of "burn out" and spend some time considering what it might do to prevent it from happening to its employees. All newFNP wants is 4 weeks of vacation per year. Yes, it's a lot. No, it is not at all unreasonable.

NewFNP suggested this change to the doc with whom she works, who in turn suggested it to senior management. NewFNP is anxiously awaiting their response. Her passport is current and aching for some new stamps.

It's nippy out

Ah, fashion. NewFNP loves fashion. NewFNP loves shopping. Just to descend into the warm embrace of the Prada SoHo, to flirt with the sassy Sigerson flats, to luxuriate in the sensation of a Theory cashmere sweater against one's cheek - even at the outlets! NewFNP loves it all.

There are, however, some fashion trends newFNP just can't endorse. These include MC Hammer pants. Can't touch this? Yeah, no shit - who would want to with those baggy ass yellow trousers? Also on the list are jelly shoes, even Marc Jacobs jellies. A current fashion forward look which newFNP finds revolting are the gladiator sandals. Go away with your leather ties up your legs. It's ugly and slutty looking.

A look that has likely not graced the pages of Vogue or Marie Claire in some time might be the half-shirt. As fashion forward newFNP readers know, longer tees are in. Bare midriff - out.

Apparently, our 275-pound walk-in yesterday morning didn't get the memo. She also must have missed the memo that it is important for breast health to wear a bra. She clearly missed the memo stating that one's ample bosom belongs inside one's half shirt as opposed to hanging out of the bottom, nipple pointing directly to the floor.

Is newFNP wrong, or is it very unusual for a woman to bear her nipple in public? Granted, newFNP lives in a rather progressive city where the climate is mild and where boobs are an important accessory. Nonetheless, it is newFNP's opinion that one must be utterly divorced from reality to A) find it acceptable to share one's lady-goods with all of the clinical staff and patients or B) not realize that one's nipple is actually out of one's shirt! I mean, come on, isn't it even a little cold? Isn't there a breeze with which to contend?

Bottom line: newFNP is no conservative, but she votes to keep the nipples in the shirts when in public.

I had this pain....

When newFNP has a pain that self-resolves, she is thankful and happily moves on with her life. That is not the case, however, for many of newFNP's patients. I cannot begin to tell you the frequency with which I hear of bygone aches and pains, now entirely resolved.

So you say that your back hurt 3 months ago? Interesting.

What's that? You had a headache last year, just once and then it went away? Well, aren't you a medical miracle.

Pardon me? What caused that pain you experienced last July? NewFNP must confess, she'd be hard pressed to say.

Lest anyone think that newFNP is an asshole, she does in fact inquire as to whether there are any other health concerns that might have brought the patient to the clinic. Most frequently, the answer is no. Sometimes, however, there is another chief complaint.

One such example is my mid-30's male patient who segued from resolved pain to constipation. Ah, poop. Now there is something you can really assess and sink your teeth into during the history-taking!

For instance, when was your last BM? Today.

I see. And how often do you have a BM? Every day. Twice a day.

This is the point during which newFNP questions her Spanish skills. Twice a day? Constipation? Something is not adding up!

OK, well, twice a day falls well into the range of normal...

At this point, newFNP's patient won the Brown Star Award when he disclosed his normal bowel pattern of three movements per day. Maybe the day after Thanksgiving, but every single day?!?

As newFNP sees it, Mr. Poopie has just saved himself an estimated roll or two of TP per month, not to mention an estimated 30-45 minutes per week away from the throne.

Perhaps he could devote that saved time into an extra workout!

Exactly

Every day, am I right? Thirty minutes? Yeah, me too.





Sorry - font so small and newFNP so unable to fix it. Caption reads: Be honest - how much are you exercising?

Strapped for cash

No, newFNP is not here to complain about salary, although it is too little to support major urban area rent, plus shopping - and not even at Barney's, plus student loans. No, at this point, it seems as though newFNP's clinic has bigger fish to fry.

You see, as in many other metropolitan areas, newFNP's metropolitan area has a significant population of uninsured people. NewFNP's clinic offers 100% free services to these people, including the dispensing of some medicines. No, we do not offer Botox, but we will do our part to keep a patient's A1C at a reasonable level. As such, newFNP's community health clinic in positively out of money for uninsured patients. Imagine newFNP pulling her empty pockets out of her flattering Theory trousers, shrugging all the while, and you'll get the idea. The well is dry.

So, what next? How does newFNP provide an acceptable level of care to these patients if she can neither order labs nor dispense meds? NewFNP is already sensitive to the financial strains of community health practice. Should newFNP provide more thorough care to her insured patients than she does to her uninsured patients? The thought is unsavory at best. And unethical, according to newFNP's ethics.

Our finance department has placed a stop on all of our orders as a result of these dire straits. How much has this administration spent on Iraq, Afghanistan and the bullshit Social Security overhaul? How much was spent on a certain state's special election in 2005? How much do the Boston Celtics earn collectively? NewFNP will tell you what - it sure as fuck wouldn't take billions to keep our patients healthy.

So far, newFNP's clinic remains relatively well stocked. However, if we run out of gloves, newFNP is placing a moratorium on all rectal exams. Hey, you've gotta draw the line somewhere.

You can't keep a good newFNP down

Since newFNP last exposed herself to a patient's aromatic purulent discharge in a not-altogether successful attempt, newFNP has incised and drained not one, but two further patient lesions.

Lesion one: lady business abscess. OK, not exactly lady business but suprapubic in locale and wholly a result of picking at one's ingrown hair. Hands. Off. Ingrowns. I restate my case initially argued in "Picky Evolution."

Lesion two: epidermoid cyst. NewFNP has been waiting for this since she first became acquainted with one during her independent study in derm.

NewFNP is floating in her derm dreamworld. Oh, how newFNP loves derm. Bring on the Retin-A, kiss that acne and those wrinkles good-bye. NewFNP would love to scrapy-scrape your big fat plantar's wart, just as she would love to inject your inflamed acne lesion with kenalog. NewFNP loves to draw pics of derm lesions. NewFNP simply loves derm. It's a pure, unadulterated love.

OK, back from dreamworld. So, an epidermoid cyst. Not pretty. It forces one to utilize culinary analogies when describing cyst contents: cheesy. Soft cheese. Soft white cheese. Rondele, anyone? The I&D is exactly the same, except that you want to get the sac which contains the contents out in order to prevent recurrence and numbing the patient is so much more difficult. The contents of the cyst are firmer and therefore require a larger bored syringe in order to introduce the lidocaine. Ouch, big fat needle.

What can ruin a perfect I&D is another provider's student attempting to horn in on the I&D action. And by horning in, newFNP means asking not once, not twice, but five times to either perform or observe the I&D. At each query, newFNP replied 'no,' each response becoming progressively more firm and annoyed, the last of which being, "You can stare at me all you want; the answer is no." Is the student six years old? No, no she isn't. Yet newFNP found herself speaking to her as though she were. There is a reason that newFNP does not have a student: because newFNP needs the experience herself. NewFNP still is gaining comfort in her role as pus-expressor.

Note to all students: when your preceptor says 'no,' there is a reason. Don't push it. Should newFNP even have to tell anyone that? NewFNP is certain that her readership is already savvy enough to realize the non-kosher maneuver by our student.

In the end, not even pushy student could spoil the supremely successful I&D. NewFNP was even able to disrupt and express the sac. You can imagine my happiness - bordering on beatitude.

Out of the mouths of babes

NewFNP has fallen in love with the well child visit. Yes, it's true that sometimes the 13-year old well child weighs more than newFNP. Thankfully, those visits are rare enough. But for the most part, well child visits afford newFNP a break from diabetes and BMIs of 45. NewFNP likes all kinds of well child visits now, but has always held a soft spot for teenagers. Especially ones that ask funny questions.

So, all in all, an average 14-year old male well exam. Thin, plays field hockey (quite unusual in my inner city area), respectful, has all parts intact and has no inguinal hernia. Testicular torsion education - done. Safer sex/abstinence education - done. Repeated denials of current or prior sexual activity - accepted by newFNP.

As always, when about to exit the room, newFNP asked, "Do you have any questions?"

"Yeah, I have a question," he replied. "Is it bad to masturbate?"

The way he asked was so sincere. I set the chart on the counter, faced him squarely and said, "No, it's not bad. Everybody does it. Just don't get caught."

He was visibly relieved. Whacky kids!

You never forget your first

It's true for any number of experiences. First kiss, first love, first bad grade (not that newFNP would know anything about that), first abscess I & D. Now, let me go on the record as having stated that newFNP likes gross stuff. But what newFNP does not like are gross smells. Seriously. NewFNP has never eaten ketchup because she is repulsed by its aroma.

Here is the sequence of events:

12:30 patient: mucopurulent cervicitis
12:45: lunch
1:15 patient: abscess

The smell. Holy shit, the smell. First of all, it was an ass abscess. Top of the rump, right gluteal fold. Second of all, there were 5 of us in the small MF-ing exam room. Me, the patient, her sister, the super-MD I work with, and my favorite MA who lives for nasty procedures. Again, the room is small. The room was also hot. And did I mention the stench of the abscess? Can you see where this combination of forces leads?

So, prep, anesthetize, cut, express, express, express, express, express (you get the idea), whiff, feel faint, get hot and clammy, realize you are about to hit the deck, call for back-up, sit, regain composure, express, pack, cover. Try to get the smell out of your memory. Try harder. Keep trying. Visualize the relative beauty of the cervicitis. Thank the heavens for bullshit URI appointments.

And a tip: for those who are also new to abscesses, my MD told me that the pH of the pus weakens the effect of the lido so numb 'em up somethin' good! Happy draining!

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?

Home sick

No, not 'homesick' as in newFNP is at work and missing her 1-bedroom apartment, but home sick as in see 'formula for success.' More time to devote to old NYT crosswords and The New Yorker.

But anyway, the time spent at home sick can't be all fun and games and cursing one's stabbing abdominal pains. As such, let newFNP tell you three little words that will make any newFNP truly embrace her 'sit-near-the-door' policy.

"I hear voices."

Super. I'm 30 minutes behind schedule and you hear voices. Are you sure you don't just have a cough?

Allow me to set the stage. My mid-40's patient was sitting on the exam table, paper gown and drape in place, and had an affect that quite frankly screamed medicated mental illness. She lacked emotion. She was treated with 2 anti-psychotics and 1 SSRI. Perhaps newFNP should let her psychiatrist know that something in her med cocktail wasn't fitting the bill.

So here newFNP is with the voice-hearing lady. After enquiring as to what the voices said to her and thinking, "please don't let it be 'kill the nice blue-eyed NP,'" I was relieved to hear the relatively benign, "Well, they are babies and they are telling me that I am their mother." OK, doesn't sound emergent.

Then she proceeded, as earnest as could be, "Is that normal?"

Hmmm... normal. Possible responses include:

a) "Normal, shnormal."
b) "I think the attraction to motherhood speaks to a lot of women very strongly."
c) "Who am I to say what normal is?"
d) "No. Shit no, that is not normal. Fuck!"

Now, if community-health-newFNP was an infertility-newFNP, she would lean more towards 'b'. But my community health clinic's scope of practice does not include infertility issues and this lady wasn't speaking about her deep-seeded inner desires for pregnancy. I chose a softer version of 'd' with a splash of 'b' thrown in for flavor.

This patient was not a sexually active lady, but believed wholeheartedly that there was a possibility that she was hearing these voices because she was, in fact, pregnant. Now that is getting into a whole area of religion and mental illness with which newFNP is not comfortable. Urine hcg negative. Let's get you in to your psychiatrist.

All in a day's work.

By the way, the swamp nurse article in this week's issue of The New Yorker made newFNP's job look like no work at all. NewFNP is all manicures and pilates compared to Miss Luwana. Here is a quote from the article:

"The mom I'm working with now is a sixteen-year-old unmedicated, bipolar rape victim and crack-addicted prostitute with a pattern of threatening to kill her social worker, who recently abandoned her baby at her ex-boyfriend's sister's, and who has an attempted murder charge in another situation..."

Now that makes me feel like I am working in a private practice.

The formula for success

Gentle reader, it is vomiting and diarrhea a-go-go here in newFNP land. We have seen countless children over the past few days with all manners of fluid evacuation. Patients have it. Staff members have it. Children of staff have it. Will anyone escape? My facialist is always telling me that I need a colonic in order to have perfect skin. Maybe she's got it all wrong. Maybe I just need some acute gastroenteritis to flush out the toxins!

Alas, the toxin-flushing argument is likely not going to be a winner with a worried parent. So what do you tell the patient's worried mom? Sure, fluids, fluids, fluids, but how much exactly? No worries, newFNP is here to provide the answer to that pressing question. As newFNP always says, there is no time like the present to review the exciting world of pediatric maintenance fluids.

Here's the formula:

First 10 kg: 100/ml/kg/day (aka 1000 ml if the kid is a full 10 kg - see how easy this is!)
Second 10 kg: 50/ml/kg/day
Each added kg: 20/ml/kg/day

For example, a 28-pound (13 kg) kid requires 1000ml + 150ml = 1150ml/day. Let's divide by 30 and tell the patient something they understand: No less than 38 ounces in 24 hours, buddy.

See, easy peasy! That is, if you have a calculator or are John Nash.

Oh, and newFNP is certain that everyone already knows to get a urine on these kids. A nice little quantitative measure of current hydration status. The whole "sunken orbits" is a little too subjective for newFNP. Maybe the kid was just not blessed with a doe-eyed countenance! Does that indictment really need to be a part of the permanent medical record?

Happy calculating!