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.