And a-one and a-two

Everyone has euphemisms for the act of defecation as well as the product, do they not? BM. Dropping the kids at the pool. Poop. Number two. Around newFNP's house, the act is called going to London and the product is London. Don't ask, as the terms were not invented by newFNP herself. She is certain, however, that their origins are not Anglophobic in nature.

NewFNP thought that she had heard all of the shit-slang until a nine-year old boy enlightened her. He was in for diarrhea so newFNP was asking all the usual questions. Vomiting as well or not so much? Watery or some formed stool? How many times a day? Fever/chills? Foreign travel? Food-borne illness, perchance?

And finally, newFNP asked the kid whether he had gone to the bathroom that day? He replied in the affirmative. "Number one or number two," newFNP asked.

"Number three," he replied.

NewFNP is thirty-three years old, has nine years of higher education, and she never, ever knew that a term existed for diarrhea. They just don't teach that kind of shit in the Ivies. Ivory Tower indeed!

Number three. Awesome.

***********************

Click here to find out how your own number two rates!

A shout out

How do people work and have a family? NewFNP cannot imagine how she could manage both.

NewFNP left her house at 7:30 this morning. She worked, worked, worked, worked, worked - you get the picture. Then it took her thirty full minutes to drive five miles to her gym. She worked out for one hour while listening to iTunes and reading her prestigious alumni mag and then spent the next twenty-five minutes driving home.

Fucking major league baseball - can't those dickholes make a shuttle to the stadium so a sister can get home after a long day at work and not sit in a line of traffic with people sporting face paint and foam #1 hands?

Anyway, newFNP rolled into her house around 7:45, hit the showers *and then* began to prepare dinner. Thank God for leftover daal in the fridge. Then dishes, lunch for tomorrow, a little reading of "The Tipping Point" and now her newFNP sits, wondering how in the world parents do this?! And single parents - holy smokes! They must be perpetually exhausted.

So hats off, baby. Props to those parents who work like dogs and come home and work some more. How in the world do you do it?

Yellow fellow

Some of newFNP's more diligent readers might be wondering what, in fact, happened with Mr. Alcoholic Hepatitis. Perhaps some are even wondering what in the world they might do if they found themselves with a similar patient.

Well, wait no longer because newFNP's boyfriend is out of town, the David Sedaris article in this week's NYer is read and newFNP is therefore here with all of the answers. OK, maybe two or three of the answers.

The single most important intervention is complete and total abstinence from alcohol. Bo-ring! NewFNP recommended this several times to her young patient and, as previously noted, referred him to AA. She gave him a multi-vitamin because who can get their 5-9 servings of fruits & veggies if they are chug-a-lugging beer after beer?! And she checked his liver enzymes and acute hep panel, just to be on the safe side. What else could newFNP do? If newFNP worked in a fancy clinic, she would have ordered an ultrasound and perhaps even a liver biopsy. But newFNP works in a not-so-fancy clinic so her patient's visit was much more low tech.

No acute hepatitis - nope, this sad state of affairs was brought on by good old fashioned boozing. His liver enzymes showed - no surprise here - elevated AST and ALT. They weren't off the hizzie, however, just 193 and 110 respectively. But his bilirubin - holy toledo! Normal values max out at 1.4 mg/dL and jaundice is typically diagnosed at 2.5-3 mg/dL. Homeboy was rocking a bili of 24.3. Good day sunshine!

He is scheduled to come in on Saturday. NewFNP hopes that his eyes are no longer the color of a highlighter pen when she next sees him.

For those clinical die-hards out there, click here for an article about jaundice in the adult. God, it's a fascinating read. It's as good as Judy Blume's Wifey.

Axial load - of crap!

NewFNP is fortunate to work in a practice site where there are exceedingly few patients who are drug seeking, unlike her good pal BostonFNP who has, a number of times, had to revive people who have overdosed in her clinic's bathroom. The only things that newFNP's patients are overdosing on are carbohydrates!

After a while in practice, one just gets a feeling as to who is bullshitting and who is in real distress. However, newFNP doesn't want to make the mistake of letting her gut override her intellect and thus attempts to approach each patient as though their complaint is valid. Sure, it can be a real challenge at times, but newFNP tries, people, she really does.

NewFNP's first walk-in patient of the day started with a call to the on-call phone last night. NewFNP's colleague fielded the call and let newFNP know that this patient would be coming into the clinic. The patient started out her visit by giving the front desk clerk shit when she had to fill out paperwork as she was here "with an emergency" - low back pain. Yes, a little lumbago is right up there with crushing chest pain and profuse intractable bleeding! She then proceeded to evade newFNP's questions about how she hurt her back until her shifty-eyed husband prompted her to relay her history. It didn't involve any trauma, it didn't include any radiculopathy, it was free from any form on incontinence - thank goodness!

NewFNP proceeded to the exam. Straight leg raise - negative. Deep tendon reflexes - 2+ bilaterally. Palpable spasm - absent. Axial load - positive.

For those of you unfamiliar with the axial load test, wary (astute?) clinicians use it to detect malingering. One simply applies downward pressure to the top of the head and asks if it results in pain. It shouldn't.

NewFNP always feels a tad guilty about employing it. She feels as though she is conducting a sting operation. Is the patient lying to get the good drugs? Is the patient who is experiencing true pain thinking that by replying in the affirmative, she is more likely to get the care she needs? Who knows. In newFNP's practice, patients are very prone to expressing their pain in no uncertain terms (see Ayyyyy me duele!). It's tough for newFNP to see through that manner of expression sometimes.

Honesty and trust are so crucial in the history and exam. This patient didn't seem honest with newFNP and it is likely that neither of us trusted the other. NewFNP wrote her a prescription for Ibuprofen and Cyclobenzaprine and advised gentle stretches, ice & heat and to continue modified physical activity. Return to clinic 4 weeks prn.

Mellow yellow

NewFNP has an M.A. who is unflappable. Nothing fazes her. In fact, in thinking about her, newFNP has just realized how much respect she has for this M.A., a powerful and seemingly fearless woman.

Well, today she was a-tremblin' with the site of dark, dark brown urine sitting in her lab. She walked into newFNP's office and said, "NewFNP, that man's urine is black." As newFNP walked in to take a peek, she informed newFNP that, in addition to having urine the color of Dr. Pepper, his eyes were yellow.

It is so nice to have a diagnosis before one even walks in the room. Of course, that would only be dealing with the medicine aspect of Mr. Big Liver. NewFNP wanted to get to the bottom of this mystery; she wanted the back story as to why this 30-something year old man's body was poisoning him and how he poisoned it.

When newFNP walked in the room, she was startled by the yellow eyes. They were really yellow, some might say goldenrod! They were Michael Jackson 'Thriller' yellow. Even his skin had an eerie golden hue and newFNP doubts that her patient had spent much time applying faux tan. It has been the exceedingly rare case in which newFNP was able to palpate a liver, but this guy's liver was the size of a small child.

Turns out that he had broken his foot last October, subsequently lost his job and began drowning his sorrows in 6-12 beers per day, by his own account. Likely a little more given that we all under-report our vices, do we not? He did stop drinking for six days when his eyes started to turn the color of French's mustard and did not experience the DT's, so newFNP felt confident that she could advise him to go cold turkey without bringing on a potentially fatal consequence.

AA referral in place. Multivitamins dispensed. LFTs pending. NewFNP can't wait.

*****************

Not to turn this into a gossip column, but Padma Lakshmi is fucking crazy. Beautiful, yes, but crazy for divorcing newFNP's other Indian man, Salman Rushdie. Some people just don't know how good they've got it!

Bienvenidos

A while back, newFNP was feeling like she needed to grow and to have some different experiences in her role at the clinic. She has attempted to engage her clinic manager and some collaborative partners about creating classes and educational materials, but the reality is that newFNP is stuck in the clinic all day, every day seeing patients. No one wants her anywhere else.

Well, newFNP needed something new! Something invigorating! Something that made her want to wake up and spark some change.

So newFNP contacted her alma mater and let them know that she would be willing to precept a master's entry student. And voila! NewFNP's first preceptee is starting this week.

Is it too much to hope that this student is jaded, bilingual and in possession of a potty mouth? Or at the very least that she in accepting of these very things in a preceptor?

July 2007 baby. NewFNP rocking the preceptorship.

What's up, Sicko?

NewFNP and her Punjabi boyfriend hit the theater and checked out the new Michael Moore film, Sicko. NewFNP is hesitant to call it a documentary as it certainly was envisioned to do more than increase knowledge, but it certainly was not created solely to entertain its audience and therefore falls outside newNFP's definition of a movie.

Like the NYer, newFNP wishes that Sicko would have dealt more with the faults of insurance coverage and with how many Americans actually support universal health care rather than on some of the theatrics, but newFNP is a one-trick pony in this arena and her documentary about the subject would be boring as shit and would have had lots of swears and no one would want to watch it. Moore's film, on the other hand, showcased two very compelling stories about regular working folk who had HMO coverage and who died as a result of red tape and cheap, cheap, cheap decision makers who denied necessary care.

NewFNP is not wholly opposed to the idea of an HMO - an insurance designed in response to the over-consumption of medical care and the ordering of excessive tests in the fee-for-service system. However, who cannot deny that it is fucking rotten to have rewards for flat out denying care. And emergencies are emergencies - people need to get to the closest ED, not the closest in-network ED.

Shit, newFNP could make billions if she were just more of an asshole. She denies care on a daily basis just so that she can selfishly leave clinic on time instead of taking a walk-in pap test, but she never denies someone care, even at 5PM, if they really need it. So maybe newFNP couldn't make such bank after all. Damn, newFNP just shattered her own dreams of riches in the course of two sentences!

NewFNP dealt with her own "denial" moment today when an administrator at the clinic told her that she couldn't refer a patient to a partnering organization for post-partum depression because this organization wasn't a part of the right collaborative. What the fuck? There is exactly one resource in newFNP's area for uninsured women with post-partum depression and newFNP used it. No, this normally very with-it administrator was adamant that the patient wait and go through the referral process. Referral to where? The fucking Hubble Space Station? Disneyland? Buckingham Palace? The hospital that let a patient die on the floor of the emergency room?

NewFNP knows that universal health care isn't "the" answer, but it sure as hell seems like a better solution to what we have now and, call newFNP a leftie, but it seems like the ethically right thing to do. A wealthy nation should care for its people, should protect the health of the nation at the individual level as well as the community level, and should acknowledge that people cannot be productive members of society if they are unwell. For Pete's sake, newFNP is less productive if she has a fucking pimple! Imagine if she had pink eye! Or diabetes, hypertension and dyslipidemia.

So, anyway, after you all see Knocked Up, see Sicko. They both have to do with health care, in a way, so maybe you can get your popcorn reimbursed and call the time spent "continuing education."

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.

Relationship issues

When you work with someone every day, you have a relationship with them - like it or not. NewFNP is very picky about her relationships, although she has made some questionable decisions in the past. Let's just say that newFNP is a wiser woman for them!

She is now in a relationship with a new OB/GYN at work. This OB/GYN has been in our clinic for a little under a month. NewFNP was out last week so the relationship is still a fledgling one. This relationship, however, is very unlike the honeymoon phase in other relationships during which all you want to do is make out, eat dinner and make out again. NewFNP thinks that under non-clinical circumstances, she and this OB/GYN may be friendly. Under work circumstances, newFNP is ready to snap.

In newFNP's clinic, the prenatal population cannot support a full time provider. On the other hand, the uncontrolled diabetics, depressed patients and kids with URI's provide a never-fucking-ending stream of work for newFNP while the OB/GYN leisurely sees her 10 patients per day. This pace leaves OB/GYN plenty of time to point out the flaws in care she sees in the charts, the flaws with our clinic's MA's and the flaws in systemic issues, and man alive, does she ever take advantage of all this free time. Unfortunately, the maelstrom is all directed toward newFNP while she is in the midst of charting, writing letters, filling out forms, helping MAs, etc.

Does OB/GYN think that newFNP has a fucking shred of control over any of this? Patient care notwithstanding, newFNP believes it safe to say that any input she may have into overall administrative issues is placed directly into the "whatever" file. NewFNP may exude the cool professionalism of upper management, but in her clinic, she is nothing but a worker bee.

OB/GYN's complaints struck a chord when she noted that a prenatal patient disclosed that her husband had been beating her throughout her pregnancy and it hadn't been addressed and it's our responsibility, yada yada yada. NewFNP looked through the chart. This patient had been screened for IPV at every visit, admitted to it once and was sent to the appropriate resource. Does OB/GYN want newFNP and the other providers, all of whom see full patient loads, to go Guantanamo-style on the patients in order to get information from them? NewFNP wants OB/GYN to work for a month before she starts pointing out all of our flaws. And even then, she should learn a little tact or keep her trap shut.

As newFNP was walking out the door, OB/GYN asked her to contact a patient for her. NewFNP encouraged her to ask our LVN to do that as he would be in the clinic a full hour after newFNP left. No, OB/GYN left it for newFNP. Unacceptable, but newFNP was too pissy to deal with it in an appropriate manner.

NewFNP is admittedly a little low on emotional reserves this week as her cousin died last Monday. But even when newFNP is at full reserve, she takes it very personally when other providers point out what they deem mismanagement when it is done in a mean-spirited fashion. NewFNP isn't even responsible for some of the visits about which OB/GYN is complaining, but she still takes it personally. All of the providers in newFNP's clinic strive to deliver care that rivals private practice standards given our resources. NewFNP is open to teaching and constructive criticism, but assholery will not be tolerated.

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.

Addendum

How could newFNP have forgotten to encourage all new NP's to ask their potential employer about the number of patients you are expected to see per day?!?

See, this is why newFNP needs lists.

A new MD in our practice told me that at her former employer, Planned Parenthood, the providers saw 50-60 patients per day. Can you imagine? NewFNP just about had a stroke when she heard that. Not all of those patients need exams, but nonetheless, that is a lot of vaginas in one day.

Checklist

NewFNP likes to think that one day - one fine, sweet, sunny day - she will leave her current practice and enter into a world where practice isn't so, how might newFNP put this, fucked. When considering this throughout her workday, newFNP finds herself thinking that she should remember certain aspects of her current practice that are troublesome and should write them down in order to wean out practices that may continue to vex newFNP.

Given that graduation is right around the corner, newFNP thought that she would share some of these ideas with her readers. Now, when newFNP graduated almost two years ago, she felt as though she should pay someone just to hire her. That feeling lasted for all of three days of work and newFNP strongly recommends against feeling that very way.

Take heed, new grads. You will work your ass off.

Thus, point one. Research your salary. NewFNP's starting salary was reasonable, but she negotiated a big increase her second year based on internet research. In newFNP's clinic, the NP's see as many patients as the MD's and newFNP works damn hard. She, therefore, has no problem asking for big salary bumps.

Point two. Salary isn't everything. NewFNP is obsessed with saving for her retirement. 401k baby. Does your company match? Huge! Free money. Do they actually have a retirement plan because that would be spectacular!

Point three. Time off. Holy crap, will you ever need time off. So how much do you get? When newFNP begins her third year with her clinic, she will start to have three weeks of vacation per year, plus one week of CME allowance plus four personal days. It is newFNP's intention to use every single one of those days. NewFNP loves time off.

Point four. On call time. Will you be expected to have it? Is it paid? How frequently are you on call? Is there a service? What is the average call volume? Oh, how newFNP loathes her on call time.

Point five. Malpractice insurance. You need one with a tail.

Point six. Actual practice policies. Are late patients allowed in? NewFNP saw two physicals two hours late today. The receptionist did write the helpful note "patient filling up the paperwork" on the superbill, as though we are a Chevron station. When her 3:00 physical appointment showed up at 4:00, she told the manager that this was unacceptable. He basically told her to shove it. These are the types of policies that make newFNP crazy.

Point seven. Walk-ins. Is there time built into the schedule or do they just get squeezed in? In newFNP's clinic, they are squeezed in which is just a lousy system.

Point eight. Help. Who is available to you? Do you have access to databases like Cochran or Up-to-date? These are helpful. NewFNP's clinic doesn't have them.

Point nine. Licensing. Does your clinic reimburse you? They should because your DEA number and your licensing fees add up. They should also pay for CME's and the good conferences aren't so cheap. For instance, this summer newFNP is having a CME vay-cay in a relaxing location with one of her BFF's from grad school, BostonFNP. The conference is $600, the hotel is $1000. See, staying smart is pricey! Hanging out with your pal, learning and then lounging - priceless.

NewFNP is certain that she will think of more points during her days, but this is a good start. NewFNP is looking forward to taking her own advice!

Va-va-va.... hey, wait a minute

As of late, newFNP has been using her spare time in between patients to help the higher-ups at work compile data for a new program application. As such, she has learned many statistics about the area in which she works. For instance, she works in the area that has the highest all-cause mortality in her county of residence. The area has the highest rates of uninsured adults and children in the county. The majority of the residents in her clinic service area speak a language other than English at home. Only a quarter of the residents have graduated from high school. The average income is in the low 20,000's.

All this to say that the patients who newFNP serves are poor and largely disenfranchised. No shit, right? They're waiting 2 hours for a 15-minute appointment at a free clinic after all.

Generally, when newFNP is conducting a health history during a physical, the past surgical history that she elicits include cholecystectomies, BTL's, hysterectomies and traumatic injury repairs. It is rare, exceedingly rare, that newFNP has a patient who has had breast implants, a tummy tuck and a face lift - all conducted in the US. Any plastic surgeries that newFNP's patients may have had are generally conducted in Mexico.

So let's see... breast augmentation. What does that even run a person? Thankfully, newFNP will never have to know! But she thinks that it is in the neighborhood of $5000. Tummy tucks? $7000? Who the fuck knows? And a face lift? What, another $5000?

So if you are dishing out upwards of fifteen grand to spruce up the bod, it seems egregious to then seek out the services of a free clinic and use public funds for your physical. At the very least, it seems as though a generous donation is in order.

NewFNP didn't say anything, though. She just did her first implant breast exam and then sent out the referral for the mammography.

Breaking the law

It was yet another busy Monday in newFNP's clinic and, with newFNP still fighting her URI, she was fighting to stay afloat. She has eight charts at home to finish and some unfinished business to attend to tomorrow.

As such, newFNP was certainly not counting on a knock on her exam room door at 4:15 as she was conducting two well-child checks on siblings. She never expected her colleague FNP to say, "You have got to see this. Someone forged a prescription on a patient you saw last week."

But this is, in fact, exactly what happened.

Apparently, the two-year old patient's mom felt that the Ibuprofen prescribed by newFNP just wasn't enough. She thought that she should just add on "amoxicillina 250mg." Just like that. Just a Spanish language medication and dosage written in chicken scratch above newFNP's graceful and fluid script.

Thankfully, the pharmacy faxed over the prescription in order to verify it. They, however, asked newFNP to verify the sig, not to verify that it was a big fat forgery. What the fuck? Doesn't the pharmacist say something to the patient? Something such as, "Ahem, do you know that it is fucking illegal to forge prescriptions, you cow!?! You know, illegal as in jail."

The patient's mom had the audacity to call the clinic today, demanding that her child be given Amox and threatening to take him to the hospital, change clinics and make a scene if we didn't give it to her. She insisted that newFNP wrote her the prescription. NewFNP refused to talk to her. She let her clinic manager know what the situation was and went about her business.

Why do patients like this always think that threatening to change clinics is something newFNP will respond to? Please, newFNP will pay this patient five bucks to change clinics so she never has to deal with her fraudulent-prescription-writing ass again.

So long sucker!

Ahhh... cable TV

NewFNP likes to fancy herself as healthy, but here she is - sick again. NewFNP attributes her illness to being exposed to all manners of rhinoviruses day in and day out and believes wholeheartedly that it is only the most virulent of said viruses that tend to knock newFNP on her ass. Which is where she has been all weekend. On the couch, flat on her ass, in and out of consciousness, thanking God that her boyfriend had the good sense to buy a huge flatscreen TV so that she may be entertained by the likes of Dirty Dancing, CSI and Caddyshack.

Nobody puts Baby in a corner.

NewFNP did take some time during her convalescence to think about her current employment situation. She reviewed some physical assessment texts and thought about where she might be taking her career. As we all know, her attitude is in the toilet. However, newFNP would like to change that and certainly does not want her career to follow that path.

But here is why newFNP's attitude sucks.

Sometimes people just break newFNP's heart. When newFNP hears about food insecurity from a featherweight 22-year old man, it just makes her emotional. Imagine leaving one's country to come to the US, in hopes of a better existence, and not being able to find adequate food. Of knowing that you have latent TB, but not being able to afford the $10 medicine to avoid active TB infection. Of finally securing a job, but working six days per week and not being allowed to leave early to get to the clinic. There was something more about this patient, though. His modesty, his sincerity... he really touched newFNP.

Then there are the people who make newFNP want to scream. This week, a patient told newFNP that no matter how much he weighs, he never changes in size. In fact, he claimed, one time he lost one hundred pounds, but still wore the same sized jeans. "One hundred pounds?", newFNP verified. Confirmed. One hundred pounds and still a size 42 waist. Diagnosis: delusional liar? Reality challenged? How is newFNP supposed to help someone who has clearly lost touch with all that is real? NewFNP notices that her trousers are roomier of she loses 1/100th of a pound.

And finally there is that old chestnut about support staff not providing support. NewFNP does not want to micromanage, nor does she have the time to do so. But when newFNP's reputation is on the line, you bet that she will be all over the staff's asses in order to get things done. You betcha that newFNP can find 30 seconds in between patients to ask if phone calls have been made and abnormal pap logs have been updated.

A friend of newFNP's recently noted that he felt that newFNP sometimes feels anger toward her patients. NewFNP disagrees, but she certainly does feel frustration toward many patients. Quite simply, how could one not feel frustrated given the challenges one faces in community health and probably in all healthcare settings?

Working through these frustrations is one of the challenges that newFNP faces. Sometimes she is great at it, sometimes not so much.

Unqualified

NewFNP works in the poorest service area within her county. Almost every single health outcome indicator (overall mortality, teen births, infant mortality, obesity, cardiovascular mortality, insurance coverage - you get the picture) is the worst in her entire huge county. Her patients are exclusively covered by public health insurance, if at all.

So when newFNP has a patient who has some wealth accumulated, she finds it, frankly, a little surprising.

For instance, when newFNP asks her patient if she has health insurance and her patient responds that, no, she doesn't qualify for health insurance because she owns her home, newFNP is surprised. NewFNP's patient's net worth is greater than that of newFNP, yet newFNP is working, paying off five years of grad school loans and going home to her rented apartment, albeit a sweet-ass apartment with hardwood, washer & dryer and arched doorways located in a chic and safe area of her city. Perhaps newFNP will one day achieve the dream of home ownership herself, but she is currently unwilling to sacrifice her HMO and 401(k).

NewFNP's landed gentry patient must think that state-funded insurance is the creme de la creme, because she asked newFNP if newFNP "qualified" to receive it. Almost! If the state took newFNP's loans into account, she just might qualify for public insurance and section 8 housing!

At any rate, newFNP believes that this speaks to the need for universal health insurance. Should newFNP's patient have to sell her house in order to qualify for public health coverage? Does being a homeowner make newFNP's patient a woman of means? Might newFNP's patient end up costing the public health system more money if she can't get the care she requires? No, no, yes.

NewFNP does not like to think about how much longer we have until the next presidential election, but is she ever hopeful that the pendulum will be swinging left!

A community health fairy tale

NewFNP works for an organization that has four clinics. She is generally at one site, but floats from other sites time to time. Some might say that we are all sister clinics. Others might call one clinic or another an evil step-sister.

As newFNP's readers know, newFNP's clinic is down one full-time provider. The other NP works three days per week. That leaves newFNP alone two days per week. So fine, newFNP has to go it on her own. NewFNP has to fill out the paperwork for all of the kids needing school physical documentation, organize the type 2 diabetes group, help the HR director re-apply for the HPSA score and write letters for patients applying for disability. By the way, is having dyslipidemia a disability? Hmmm, newFNP thinks not. Denied!

Did newFNP mention that she has zero hours of administrative time during her work day?

All this to say that, frankly, newFNP doesn't need anything extra. NewFNP most definitively does not need another clinic, her organization's biggest clinic, sending her a walk-in s/p abscess I&D wound care patient. And furthermore, newFNP does not need that patient to walk-in without a either a courtesy phone call from the dickhead at the front desk of the other clinic or a copy of the patient's registration info and progress note faxed from the clinic.

Why can't other people understand that taking five minutes to extend professional courtesy makes a difference? This is what continually floors newFNP about working in community health. Some of her colleagues just don't have common sense, nor do they think to extend courtesy to each other. Certainly a phone call is a chance to express thanks for the extra work, to give a heads up that you might be keeping your staff over an hour late due to the complexity of the walk-in patient and that you will likely be missing a date with your boyfriend.

But no. In walked newFNP's patient with a 2-inch gaping wound in her buttocks, covered with approximately 800 bandages and 35 rolls of tape. It took 15 minutes just to get the bad dressing off this poor lady's irritated skin. After diluting the wound with one liter of diluted hydrogen peroxide, newFNP packed her patient's lovely lady lump with three feet of iodoform. Three feet. During this process, newFNP's patient told her that the other clinic sent her because newFNP's clinic was bigger, that the evil step-sister clinic was closing early and that they didn't have the supplies to do the dressing change.

Interesting phenomenon indeed. The clinic had the supplies to slice open this woman's butt, pack the wound and cover it, but not to check on her healing and change her bandage.

It's one thing to have patients dumped from other clinics, but to get screwed by one's own colleagues! That just leaves a bitter taste in newFNP's already tart mouth.

Bathtub safety

NewFNP has a hunch that it is going to be a grand day at work when, driving to work at 8AM, she sees no less than five commercial sex workers standing on consecutive corners, white patent faux leather thigh-high boots, Daisy Dukes and Huggy Bear caps-a-plenty. Is there no vice squad in newFNP's major metropolitan area? Can the lady walking down the street in a tee-shirt and no pants or underwear find it within herself to cover her huge ass? What the fuck?

Seriously people. Can't we all agree that there are certain things that newFNP, as well as the majority of the rest of the world, do not need to see except at the movie theater or on C*O*P*S? There is only so much vice that newFNP can tolerate so early in the morning. This morning exceeded newFNP's quota.

So, hours passed with no obvious prostitution, leading newFNP to think that her day was normailzing, when newFNP was saw the chief complaint of "hurt her vagina." Now, newFNP is no stranger to curiously worded CC's, such as "little ball on the peanuts, " "soap in the right eye x 9 days" and "cough and flames x 2 days." What does newFNP have, a dragon for a patient? So, clearly, "hurt her vagina" isn't the oddest CC, but it's no "med refill" either.

Apparently, newFNP's 200-pound patient had slipped while exiting the tub. Her fall was broken by the tub wall, with her labia bearing the brunt of the force. Her left labia majora to be exact.

NewFNP uttered the words "oh shit" upon seeing her patient's horribly swollen purple labia. It was the size of newFNP's fist. It looked like a seashell. NewFNP imagines that she felt what all men feel when they see another man take a hit to the testes. Youch! Again, newFNP did screen for abuse - none. All of the pelvic bony structures were intact and the patient had full ROM at the hip, thus no x-ray for this uninsured patient.

Ice. Ice. Ice. Ice. Ice. Frozen peas baby. Mold 'em to your downstairs. Motrin 800mg TID with food. NewFNP thinks that pelvic rest is an obvious plan, but said it nonetheless. A little prayer that this will resolve quickly for the patient.

Man, oh man. What a day.

NewFNP's patients need the ERA!

Gender equality has yet to make it to newFNP's patients. Sure, in our practice, the medical and dental directors are both women, as are the CFO and COO. The majority of the providers are female. NewFNP can't imagine that any of them go home to loser husbands who sit on the couch, drink beer and watch TV.

Yet newFNP has patient after patient tell me that they can't find a moment for themselves, that they care for children and homes all day long, only to care for children, homes and partners once the men come home from work. And these women have complaints of fatigue, dizziness, "low blood pressure," and sadness.

And they have no friends. NewFNP asks about friends/support systems, but these women don't have them. NewFNP screens every patient for IPV, but the majority of these women deny abuse. They are just socially isolated. If newFNP didn't have her girlfriends, oh man, that would be a grim existence indeed.

Now don't everyone go and write newFNP, telling her that she is naive and all of these women are abused and denying IPV. Please. NewFNP doesn't screen just once and she gets that it takes more than once to gain confidence. Some of these women will disclose abuse; others are just married to beer-stained couch cushions.

NewFNP knows that we are supposed to be culturally sensitive, but newFNP finds it pretty fucking difficult to be sensitive to husbands/fathers who are as lazy as tree sloths. Yeah, yeah, these guys work all day, but so do their wives. Caring for children all day long is exhausting. How much pretend play can one engage in? NewFNP isn't talking about in the bedroom now, but speaking of... Is it any surprise that these women have no sexual desire? NewFNP thinks not. In fact, newFNP is hard pressed to think of a woman who is going to want some sweet lovin' if all she does is work around the house and see her husband watch WWF while sipping on a cool Pabst Blue Ribbon.

NewFNP had an awesome 28-year old patient today who is a mother of four. She does aerobics most days making her a clear outlier in newFNP's practice. Her husband would like another baby, mostly, she believes, to keep her around the house more. She told him that is would be a cold day in hell before that happened. NewFNP felt so proud of her!

Now newFNP is all riled up and needs to see if her boyfriend did the dishes or made the bed or did something today!