Happy Holidays 2009

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

A) Time off.

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

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

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

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

And if there is someone, is he married?

******

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

Always have and always will

NewFNP has the raddest grandparents -- all of them.

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

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

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

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

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

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

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

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

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

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

You got it, Gram. Whatever you want.

Pole Position

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

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

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

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

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

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

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

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

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

Two things

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

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

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

Choice

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

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

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

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

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

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

And it's not newFNP's choice.

Saved yet again

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

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

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

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

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

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

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

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

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

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

One week follow up

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

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

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

He was also diagnosed with leukemia.

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

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

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

NHSC ya later!

It's official, bitches!

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

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

Sunken treasure

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

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

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

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

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

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

It's all so confounding for newFNP.

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

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

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

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

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

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

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

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

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

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

No. Just no.

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

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

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

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

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

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

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

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

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

Reform

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

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

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

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

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

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

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

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

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

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

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

Pura vida

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

Lost in translation

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

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

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

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

What a sophisticated misspelling it ended up being.  

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

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

Dementia praecox et Cocoa Brown

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

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

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

Do.  Your.  Kegels.  

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

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

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

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

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

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

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

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

Whew!

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

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

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

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

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

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

Guiding Light

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

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

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

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

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

NewFNP is nothing if not handy in a pinch.   

A very happy 4th anniversary

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

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

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

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

Milk it does...

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

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

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

Shit, newFNP muttered.

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

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

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

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

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

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

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

4.9.  From milk!??!!**

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

Pass it on.

____________________

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

Broken heart

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

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

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

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

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

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

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

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

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

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

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

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

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

Heartbreaking.

When you're sliding into first...

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

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

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

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

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

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

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

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

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

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