Stay away from the windows

It has been an exciting few days in newFNP land.

In addition to the minimum 27 patients per day newFNP has seen this past week (range 27-34), we had a little drive-by shooting fatality/car crash in a too-close-for-comfort location. And by that, newFNP does mean visible from the front door of the clinic. NewFNP was all for closing up shop that day but alas - once the fun and games of clearing away the body and the cars was taken care of, all returned to normal. Only the disconcerting knowledge that newFNP does, in fact, work in the hoodiest of hoods remains.

Thankfully, newFNP had an unexpected treat today. As she deftly moved around her patient to partake of a thorough lung exam, she was treated with a rare sight: a mullet. A wavy mullet. Others might not find joy in the mullet, but newFNP was thrilled! It's not so often that anyone rocks the Billy Ray Cyrus these days!

It was a high in newFNP's achy breaky day.

Ahhhhh......

NewFNP hates to repeat herself, but it is tough to deny that the shit that comes out of a kid's mouth can brighten one's day.

A little background. NewFNP is averaging 30.3 patients per day this week. This is a fact that would give her CEO a big boner but makes newFNP want to stab her eye with a used needle, repeatedly. NewFNP is looking in every corner of every room for the silver lining, but newFNP is fed up. One might even say that newFNP is fucking fed up.

So thank goodness for little miracles, right? And it is unusual in newFNP's life that miracles take the form of fat 9-year olds, but it seems as though miracles do indeed work mysteriously.

This chunky guy was midway through his physical when newFNP instructed him to lie down for the old abdominal exam. Reclined comfortably, he closed his eyes, stretched and sighed, "Ahhhhh, I knew this day would finally come......" He was so serene and sincere, as though he had stepped into the day spa. Or did this patient think he had stubled upon the Best Little Whorehouse in Anonymous Urban Center?

As his mom, older sister and newFNP were chuckling, this Hugh Hefner protoge continued. "I knew that one day I would be here and be examined thoroughly." Now, newFNP knows that this little kid did not intend for his comment to sound creepy or weird - let alone pornographic - and he probably didn't even intend for it to be humorous. But he indeed did receive a thorough exam and is off to urology as a result. Did his big genital fat pad eat his testes or were they never descended to begin with? That is for Dr. Penis to decide.

There was a distinct lack of awesome little kid comments today, however. NewFNP could go for one tomorrow. NewFNP could also go for a day with 20 patients, a new Miu Miu handbag and some raspberry-colored Marc Jacob's patent leather wedges. Alas, newFNP thinks that the wedges are a more achievable desire than is a light clinic day.

Office staff rant

A tough thing about being newFNP (or supervising MD or co-worker NP) is that there are no other employees in the clinic as responsible or as knowledgable as you. In some ways, that's fine. In other ways, it makes newFNP want to yell at people and throw her pens at them.

NewFNP's biggest pet peeve in not having labels in the chart.

NewFNP is the third stop in the clinical flow. First stop - front desk. Second stop - MA/vital signs. Third stop - newFNP.

As evidenced by the above written flow chart, here are at least two people ahead of newFNP who can open the chart and see that there are, in fact, no labels. Ultimately, the front desk needs to take a split fucking second and look in the chart. Are there labels? No? Print them out!

Ten minutes later, when the MA writes down the chief complaint and sees that there is no label with which to identify the patient on a new progress notes page, she then has the opportunity to ask the front desk to print out some labels.

Now, newFNP is not sure how often the aforementioned scenario occurs, but she is quite sure that it did not happen three times today, a day in which newFNP was responsible for the care of thirty-four patients. On such a day, newFNP finds it difficult to be polite when wasting precious minutes of her time to go do someone else's job. It is not as though newFNP has neglected to mention this ever-present need for labels to all clinical staff during weekly staff meetings. To the contrary, time and time again, newFNP has pleaded with her co-workers to throw her a fucking label bone. Alas, no.

Ranking second on newFNP's list of pet peeves is incomplete or an absolute lack of lab results in the chart when a patient's clearly stated CC is "lab results." Should it ever happen? No. Should it happen daily? Hell no. Does it? Shit, yes it does. This causes newFNP to hunt down her MA and request the results. Sure, newFNP could find them faster herself, but fuck that just on principle.

There are many other things our MA's miss. Some of it a simply a lack of knowledge and newFNP is not going to fault them for having next to no education. However, newFNP attributes a decent amount of MA oversights to sheer laziness. And newFNP is pissy about that. NewFNP has struggled all year with the fact that she is working like she is on the chain gang all day long while she sees other employees looking on MySpace and taking 10 minutes to figure out from which fucking fast food restaurant everyone wants to order lunch.

Being at the top of the intellectual food chain in one's community health clinic is at times a welcome responsibility and a frustrating burden. NewFNP sincerely believes that it would not take much effort on the part of other staff to ease the workload of the clinicians. Sure, we'll see the 25-30 patients per day. Just make it a frigging smidge easier on us.

Geez!

Pediatricity

NewFNP feels that she is not alone in declaring that, for FNP students, pediatrics can be daunting. Kids have high fevers, they have weird rashes that may be viral or may be frigging measles. Who knows? What new NP has ever seen measles? What parent feels confident in the diagnosis of 'viral exanthem'?

Nonetheless, pediatric visits have turned into the highlights of newFNP's day. Why, just this week, newFNP had a five year old boy laugh and scream, "You're touching my penis!" during a regular old testical exam during a well-child check. You just don't get that kind of enthusiasm during the adult exam. A four year old boy this week told newFNP several times, "You're funny." And, damn it all, that kid is right. NewFNP was having a grand old time chatting up this four year old about school, his cousin, crying, Batman - a little sample of all things important.

For all the students, newFNP thought she would share some secrets to help overcome the fear of pediatrics for you and your patient.

1) This lesson is courtesy of Sunshine, a co-ed with whom newFNP studied. New FNP uses it without fail. Kids hate the ear exam, but looking for Dora or SpongeBob in a kid's ear will greatly facilitate the process. Sometimes newFNP tells the kid that she saw Dora running to the other ear and they graciously turn and offer the ear for examination. This tool is not limited to the ears, no sir. It works on the mouth too!

2) Making an amazed face upon cardiac auscultation is a wonderful tool to get kids interested in what's up. Of course, older kids can listen to their own hearts, but the young kids like to see that you think their body is working well.

3) Knowing when you don't have to do a full exam is important. Not every well child check needs to be a head-to-toe. If kids are scared and crying, newFNP lays off, especially if they are a regular patient. NewFNP explains her lame exam to the parent, letting them know that being scared is normal and that newFNP will provide a more thorough exam when the child is not screaming and kiding under the chair.

4) Tell parents to bring the kid back the next day if you're concerned. In newFNP's experience, parents don't appear too put out when it comes to their kids' health. You can also try obvious things like oral rehydration and fever management in the office. Duh.

"You're touching my penis!" Ah, good times.

Holiday! Oh yeah, oh yeah! Celebrate!

Ah, the joy of a two and a half-day weekend! NewFNP did have to work on Saturday but then was able to luxuriate in the glory of 2.5 days off. That is, until she attempted to return to work this morning and appreciated the hell that is the first day of school, which added a full 15 minutes onto her usual 20-25 minute commute, only to arrive to a waiting room with a population density that rivaled Calcutta.

It is entirely anecdotal yet positively indisputable that the first clinic day after a holiday weekend sucks donkey nuts.

Too. Many. Patients.

What happens in that one extra day during which newFNP is having brunch and playing Scrabble and cursing The New Yorker for not picking her brilliant caption that causes a 15 billion-fold increase in patients?

And the air conditioner in newFNP's clinic has bought the farm. Granted, that was two weeks ago but temperatures are soaring here is newFNP land and one would not call the exam rooms in newFNP's clinic 'spacious' or 'windowed,' thus creating a real issue with heat, smells - you get the picture. Perirectal abscess? Sitz baths and Keflex until the air conditioner is repaired. Not that newFNP would do that, but it seems a fair alternative given the conditions.

All in all, today was almost enough to make newFNP seek refuge in the suburbs. Or the spa. Or Barney's. Or perhaps just the H.M.S. Bounty.

Knocked up

As a part of newFNP's continuing growth, development and work stress, she has taken on the role of prenatal care provider.

Here is newFNP's ideal first prenatal patient: 25 years old, normal weight, 8-10 weeks pregnant, non-smoker, no drugs or alcohol, taking prenatal vitamins, stable home life. She can have a cup of coffee per day because, come on, newFNP isn't a fascist.

Here is newFNP's actual first prenatal patient: 22 years old, G3P2 with a 7-month old, living in a shelter due to IPV, quit her 2 PPD smoking habit "2 weeks ago," in the 19th week of her pregnancy seeing newFNP for the second prenatal visit of this pregnancy, no prenatal vitamins, with both children in foster care, overweight and missing a front tooth. NewFNP knows that the front tooth isn't relevant, but it does paint a certain picture. Did newFNP mention that this patient was a walk-in? Of course she was! Only the non-complicated patients seem to make appointments in newFNP's clinic.

Trial by fire, this prenatal care bit.

Look at all of the opportunities newFNP has to provide education, support and care.

That is newFNP's new mantra. The old was one "fuck this" and that mantra just doesn't always work.

Celebrating one year of newFNP

Three hundred and sixty-five days ago today, newFNP had just completed her first day as newFNP.

NewFNP saw five patients that day - today it was thirty.

NewFNP is certain of one thing - being nice to patients makes all the difference in the patient experience of their care. NewFNP had a patient last week with cerebellar ataxia. What is cerebellar ataxia, you might ask. That is precisely the question newFNP was asking herself as she sat staring at her patient. No matter, because newFNP was nice and took time to talk to this woman. Midway through her visit, she told newFNP, "I want you to be my doctor." Well, sister, newFNP can't be your doctor but she can be your FNP even if the only thing she knows about cerebellar ataxia is that she needs to get your ass to neurology.

NewFNP also has to remind herself that many people in her practice are, quite frankly, health illiterate. Many people do not know how to care for themselves; they don't know the difference between what is healthful and what is dangerous. For newFNP, that is sometimes hard to fathom. Before newFNP was newFNP, she knew that Gatorade was not a health drink. She didn't learn that in NP school or in MPH school - she just knew from sometime long ago.

This lack of basic health knowledge is frustrating to newFNP at times, such as today when she had an urgent walk-in for, no joke, a bruise. A run of the mill purple bruise. But as newFNP felt herself thinking, "What in the motherfucking fuck is this person doing here," she backed off that ledge and remembered that this person was in clinic to get newFNP's professional and educated opinion about her bruise.

Ah, the wisdom we amass.

Although newFNP has yet to submit her request for a salary increase, she did receive a brand new chair at the end of the day today. For the past year, newFNP has had this ghetto-ass hoopty chair. No more - newFNP is now ergonomically correct and does it ever feel good. Now if she could only get a computer.

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Thanks for sharing this year, newFNP readers.

Scoot down

Quite frankly, newFNP does not understand how it is that women who have had many children, who have had prior pelvic exams, and who are in their 30's & 40's do not understand that they need to scoot that shit down in order for newFNP to do a pap. NewFNP feels a bit akin to Hannibal Lector as she repeats, "Closer. Closer, please. Closer." Imagine, if you will, a woman on the exam table, feet in the stirrups, legs fully-extended. What do they expect newFNP to do? Shimmy up on the table with them in order to get a peek at their cervices? And why is it when newFNP instructs them to move closer to the edge that they inch their way down the table? Is there an epidemic of women falling from the exam table - ass first, feet a-tangled in stirrups - that has these women stricken with fear about scooting? Ay ay ay.

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.

Fine art

NewFNP has no personal opposition to tattoos. In fact, she must admit to having had a certain attraction to some tattooed gentlemen now and again. In fact, it has been rare - if ever - that newFNP has felt morally and personally offended by a tattoo. NewFNP supposes that there is a first time for everything afterall.

While conducting a physical exam, newFNP noticed that her patient had half of a buxom naked lady peeking out from under his mid-calf-high gym socks. Not only was this lady stacked, she was also sitting with her legs widely spread, knees bent. Although her nether regions were covered by the gym sock, newFNP had a guess as to what was hidden beneath. Well, in case newFNP was wrong in her assumption, when she walked around to the patient's side, she got a glimpse of something she had never imagined anyone - save for disgusting perverts - would want eternally portrayed on their external calf.

NewFNP must confess that the artist was clearly a student of the female external genital anatomy. Professional or lay, this tattoo artist knew his stuff. NewFNP can't be certain, but she thinks that she saw a Skene's gland. In any case, is it necessary or even desirable to have a 7-inch tall tattoo of a naked and anatomically accurate lady in the doggy-style position, fingering herself , and glancing longingly over her shoulder? NewFNP thinks decidedly not.

NewFNP has thought about this a lot - not the tattoo, per se, but her reaction to it. A) NewFNP felt offended. Period. B) NewFNP did not want to continue to provide much care to this individual who clearly has low regard for women. C) NewFNP felt sorry for this person's daughter.

Maybe newFNP should have suggested tattooing underpants on the lady. Or maybe she could have just said, "Oh - I see you have a fucking repulsive tattoo. Do you have a difficult time getting laid?" But she didn't. She just did a quick exam and moved on to the next 50 million patients that day.

Gross.

But it's 4:53 PM

Here is the patient who should be the 4:45 walk-in: tinea, 1 lesion. That's it. You have ringworm, welcome. Please come in and accept my anti-fungal treatment. And then leave so that newFNP can too leave in order to make it to her overcrowded, under-air-conditioned gym prior to all of the elliptical machines being hogged.

Here is the patient who should not be the walk-in at the aforementioned time: the never before seen in our clinic 63-year old lady with the visibly pulsating carotid. It wasn't small, nor was it subtle. It was reminiscent of the boils on the truck driver's neck in 'Harold & Kumar Go To White Castle,' a must-see movie as far as newFNP is concerned.

In considering this patient, newFNP has but two words: time bomb.

Carotid bruit? No. Hugely wide carotid with a loud - and newFNP does mean loud as all getout - pulse. Is it an aneurysm? Possibly. Whatever it is, it needs more in-depth evaluation than newFNP's little community health clinic can provide. And did I mention that her BP was 144/40? Well, it was. NewFNP likes to call that a "wide" pulse pressure.

So, to sum up: wide pulsating carotid + wide pulse pressure = good-bye pulsing neck lady. Enjoy the ED. NewFNP sincerely hopes that this trip will save her patient's life.

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!