Friday, June 26, 2009

OB, oh boy!

It pleases newFNP that she continues to experience new challenges in clinic.  Otherwise, the work gets a little too rote.  Thankfully, newFNP's prenatal practice has been supplying her with a couple of not taught in school-style scenarios.

In the past week, newFNP has had five patients on the verge of labor.  Generally what happens is that newFNP educated patients on when they should go to labor & delivery and, with the exception of her eighth-grader in labor, that is what happens.

Not so much this week.  One patient presented for her repeat c-section, ineligible for VBAC due to her first c-section being conducted vertically, checked herself into the hospital and then checked herself out, only to drive to another hospital where she had the cesarean.  Another patient presented to her c-section appointment because her fetus is stubbornly breech, only to be turned away and instructed to return in a week.  NewFNP scheduled this c-section according to the hospital's protocol for breech position, not according to her own whimsy.  Whatever.

Finally, not once, but twice in the past week, newFNP has had patients present to the clinic in labor.  Her most recent patient (G3P2) was three days post-dates and had a urine dip that screamed UTI and dysuria to boot.  To top it off, she was contracting every three minutes in the exam room.   She was laughing through the contractions and they were only lasting about 20 seconds.  NewFNP, however, was not laughing.  

Here was newFNP's conundrum.  It was simple really: treat the UTI with some Rocephin and then send her to labor  delivery or just send her to labor & delivery.  Truly, newFNP thinks that either way would have been fine.  But she prefers to TCB in the clinic, rather than shuffling her patients off with business left to take care of.

NewFNP called her Family Practice MD colleague who advised her to do a vaginal exam to assess for cervical dilation and effacement, give the Rocephin based on what was going on all up in that and go from there.  

Here's the problem: newFNP doesn't totally trust her cervical exam.  She just hasn't done enough of them on pregnant ladies in labor.  Sure, if she could put her head in there with a miner's light, she could easily tell if that action is dilated.  But on a 232-pound lady who is 10 months and three days pregnant, the exam is not so easy for newFNP.  Nonetheless, newFNP strode back to the room, sterile gloves in hand, and proceeded to examine the hell out of that cervix.

And folks, that was a good cervix to assess.  NewFNP felt 5-6 centimeters of dilation and nothing but head.  NewFNP's patient, shocked, just kept laughing through the contractions.  NewFNP called her MA to deliver the Rocephin, called the prenatal coordinator to deliver the taxi voucher as her patient had driven herself to her clinic appointment, had her call her truck driving husband and ask him to turn that action around, and sent her on her way.

She gave birth to a healthy 9-pound girl a few hours later.

The fifth patient just went to the L&D floor as directed.  

So, all in all, 20% of these ladies had labors that went down as newFNP had anticipated.  Doesn't matter.  All that matters to newFNP are healthy moms and babies.  

Saturday, June 20, 2009

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

NewFNP is just going to put her bias right out there: if not a single teenager ever got pregnant again, newFNP would be just fine with that.  Sure, having a baby when one is in the 10th grade is not the end of the world.  It doesn't absolutely mean that one will never, say, graduate from high school or attend college.

But it sure as shit makes it more likely.

NewFNP concedes that it is utterly possible that the 16-year old sitting in her exam room, pregnant with twins, was not necessarily college-bound to begin with.  Most of her patients do not go on to college, but newFNP makes it a practice to plant the seed in her pediatric & adolescent patients that they have options and that college is a very good one indeed.  NewFNP recognized her patient's mom as one of the women who regularly sells champurrado outside the clinic from an orange Igloo container.  Maybe college has never been thought of as a possibility for her children, never been discussed in the family.  Maybe grandchildren will bring more joy than will the pride associated with watching your child succeed academically - newFNP just doesn't know.

NewFNP moved between the medical and social histories with this patient.  Tenth grade.  Lives at home.  Planning to continue the pregnancy.  Medical history insignificant until now.

When she inquired as to the father of the twin fetuses, her patient replied that he was involved.  
Great - that is a good start.

"Is he in school?," newFNP inquired.

"No," her patient replied, eyes averted.

"What is he doing?"

"He's working."

"How old is he?" newFNP asked.

"Twenty-three," came the sheepish reply.

Somewhat shocked, newFNP turned to her patient's mom and asked her what she thought about this.  She replied that she thought her child's Casanova was a good guy.  

NewFNP almost fell off her rolly stool.  It is a situation such as this in which newFNP imagines herself going vigilante in her hypothetical parenting world.  This is a man and a girl.  This is statutory rape.  This is one of the many reasons that newFNP is a huge fan of the birth control pill, the IUD, even the shot (of which, truth be told, newFNP is no real fan).

Her patient's mom told newFNP that she had instructed her daughter to be careful.  Be careful?? Has this mom never met a twenty-three year old man before?  Because newFNP has, and she knows that they are horny motherfuckers.

NewFNP referred the girl to high-risk OB and to pregnancy case management.  She reminded her that quitting school was not an option, that she would, in short order, have two children to support and that those children would look to her for guidance.  

It wasn't one of those encounters that newFNP walked away from feeling hopeful about the future or inspired by her work.  

She just felt sad.  And disappointed.  And angry.  At herself for not being a better counselor, at the mom for not helping her daughter get contraception and for condoning the relationship and at the guy for dating a high school student.  

Friday, June 12, 2009

Out of the rut, follow the gut (instinct, that is)

NewFNP has been caught in the hum-drum of sameness at clinic.  Paps, prenatals, diabetics, URIs.  These are the norm of clinical practice, but the routine gets a little drab.  Don't get newFNP wrong - she doesn't want to work in a emergency room, but she does like a little change-up here and there.

She got it.

NewFNP was doing an abdominal exam during a well-adolescent visit.  The kid was fourteen, had no medical history to speak of and had no complaints.  Nonetheless, the instance newFNP palpated his belly, her internal alarm sounded.

This young man was not especially skinny - just average with a smidge of baby fat.  Had he been thin as a rail, newFNP would not have been so startled when she felt his abdominal aorta pulsating very prominently and pulsating a full two finger breadths to the right of the umbilicus.  She attempted to measure the aorta and estimated about a three-plus inch width.  

NewFNP spent a while running this through her mind.  She didn't feel a mass and she could not determine the direction of the pulsation.  The only thing of which she was certain was that this exam did not feel right.  

She got Dr. Dual-Ivy-League-Degrees to consult -- she agreed that it was an unusual exam.  

Maybe this is normal for him, but son-of-a-bitch if it's an aneurysm.  What are the odds at fourteen years old?  Un-frigging-likely.  Nonetheless, newFNP trusted her gut and sent him and his gut for an ultrasound.  She is anxiously awaiting the results.