Wednesday, April 28, 2010

Bad Mojo

NewFNP has had one hell of a week and, if she is not mistaken, it is merely Wednesday.

Not that newFNP is overly superstitious, but she finds that the first patient of the day can sometimes set the tone for the rest of the day. And are stars aligned - or misaligned or crossed or something - because newFNP's first patients have been outliers, each and every one of them.

Monday's first patient was a run of the mill IUD insertion and things were sailing along as smoothly as ever. The tenaculum was at 10-&-2 and the Mirena's arms were released when the speculum went AWOL. It settled on the still intact tenaculum while newFNP's MA nearly infarcted. NewFNP should damned well know better but this tends to happen with overweight ladies and this patient was only slightly overweight. NewFNP removed the IUD and blindly attempted to remove the engaged tenaculum. If you have never tried this before, it's a task not as easily completed as one might like. Fortunately, the repeat placement went much more smoothly than the initial in no small part thanks to newFNP's MA keeping the speculum in its desired location.

At least Monday's patient was in the clinic when the situation went down. It is important to have a little background on newFNP prior to hearing about Tuesday. NewFNP is chronically early and is therefore in clinic thirty minutes prior to any other provider. So when a patient who had been standing outside waiting to be seen began seizing in line, newFNP was the only provider on the scene. The ambulance and firetruck had come and gone before the clinic was actually even open for business. And thirty-one patients later, newFNP went home.

And finally, this morning our clinic nurse brought a slurring patient to newFNP's attention. According to the patient, her methadone dose was increased yesterday. It took longer than necessary to elicit this information as the patient was nodding off during the subjective component of the interaction. She denied all drug use which may be the case but people may overdose on methadone and a good place to OD is in the hospital where there are doses of Narcan and ER physicians and IVs. Furthermore, her asthma was uncontrolled. Further-furthermore, she was six months pregnant. NewFNP put her on oxygen and a nebulizer and again invited the paramedics to the clinic.

Please. Please. Tomorrow. Let tomorrow be easy. Super frigging easy.

Wednesday, April 21, 2010

Hells Bells

For the first time ever, newFNP was jealous of a patient's t-shirt today. This is not to say that she wasn't impressed by the "other bitches just front" t-shirt of some time ago, but newFNP -- ballsy as she is -- just does not have the sack to wear that t-shirt in public. Would they even let her in J. Crew?? Maybe in Barneys Co-op, but probably not J. Crew.

Today, however, newFNP was ready to trade her J. Crew bedazzled tee for her patient's tee. From under her patient's coat, newFNP could see, in metallic silver glory, a C, a lightning bolt and a D and she knew, oh how she knew, that her 50-something year old African American lady patient was wearing a mother-effing AC/DC t-shirt. For those about to rock an AC/DC t-shirt, newFNP salutes you.

NewFNP loves AC/DC.

Her patient's hemoglobin A1c of 10.6%, she loves somewhat less.

Thursday, April 15, 2010

There's an app for that

NewFNP dodged a bullet today. Not literally, but technologically.

Outside the exam rooms, newFNP's clinic has lovely fold-down desks. In her fold down desk, newFNP has lab slips, routing slips, medication order forms and, frequently, her iPhone 3GS.

Today, newFNP looked in her desk and her beloved iPhone had disappeared. "Mother fuck," she thought, "Somebody stole my phone." She looked in the providers office and was denied. She looked again in her fold down desk and was again denied. It was at this point that she truly began to lose her shit.

She thought about why in the world she would return to a place where people are stealing phones. She realizes that poverty leads to desperate acts - such as her patient who presented to the emergency room with abdominal pain and cholelithiasis using a fake name in order to avoid receiving a bill she could not afford. NewFNP does understand that these acts are of desperation, of not seeing any other way.

Nonetheless, they are wrong.

NewFNP is not insensitive to the fact that many bankruptcies are results of medical debt. But she does not condone what is essentially stealing health care from the emergency room. The medical system is broken. But when one lies in order to receive services, then is that person a part of the problem? Or are they just making the best of a fucked up system?

Today in clinic, newFNP's colleague blew up her cell time and time again. Given that it was password protected and that the mute function is not immediately accessible if one is unfamiliar with the phone, the culprit had to ditch newFNP's phone in the baby scale. She then walked around the clinic and went to her mental health appointment.

NewFNP had started her on Paxil yesterday and made a referral to mental health -- today's appointment. She had stolen another employee's phone several days before. No one has confronted her. The current plan is to have her escorted to every aspect of her clinical appointments, but apparently to never acknowledge her sticky fingers. NewFNP's clinic manager specifically asked newFNP not to confront her.

Fine. NewFNP will keep her mouth shut. She does, after all, have her phone back. And she learned a valuable lesson: keep your shit with you, newFNP!!

But newFNP is pretty damned certain that she does not want to give her time, service and care to this woman in the future. This patient does not get to have the special newFNP touch. She spent a shitload of time (read: 20 minutes) supportively encouraging this patient yesterday. She does not want to give that of herself to someone who takes and takes and takes, then takes some more.

As an aside, this incident has caused newFNP to re-evaluate her aversion to the lab coat. Perhaps it's time to pick it up off the floor of the coat closet and bring it back to clinic.

Tuesday, April 13, 2010

Blame it on the a-a-a-a-a-alcohol

NewFNP is no teetotaler. Hells to the bells no. But she does generally drink in moderation. Sure, she might have tied one on at the Liberty Hotel one night and fallen asleep while sitting on BostonCNM's couch while holding a glass of water, only to awake some time later -- cold, confused, wet and holding an empty glass. But those occasions are few and far between.

But newFNP, thankfully, has no addictions. Two of her patients this week have been debilitated by their alcoholism. One man, newly sober, came to newFNP in follow up after having received furosemide for his bilateral pitting edema. Rather than having diuresed some of the fluid, he had gained three pounds in two days. His legs were swollen. His abdomen was taut and distended with ascites. His sclera were yellow. He felt itchy. His bilirubin was 9 point mother-effing 9. He was urinating once daily -- on Lasix! NewFNP sent him to the emergency room. But his liver is shot. And whatever happens in the emergency room won't fix the damage that decades of alcoholism has wrought.

Another patient, a man just a few years younger than newFNP, stated that he drinks at least 100 ounces of alcohol every day and has done so for the past two years. CAGE questionnaire positive 4/4. Replacing meals with alcohol. So depressed that he couldn't imagine going through life any other way. Uninsured.

A pretty decent resource in such a situation is the SAMHSA treatment locator. NewFNP printed out a list of medical detoxes for him, drew some labs, started Paxil and gave him vitamins. She called him today to see if he had had any luck getting a detox bed.

His number was disconnected.

Wednesday, April 07, 2010

She's ba-aaack!

NewFNP has four words for you people: Hot Tub Time Machine.

Even without memories of movie hilarity, newFNP is pretty stoked to be back in full-time practice. Sure, she cried at work out of frustration yesterday but, to be fair, her dog was under the weather and newFNP was worried about him. (He's fine today.) And yes, newFNP has been inundated with penile warts and emergencies and non-compliant prenatal patients.

But she is certain that she is where she is supposed to be. She is truly happy to just be back in the clinical mayhem, taking care of patients. And there is really something to be said for coming home when it's still light out, hanging out with your pals, walking the dog and watching DVR'd Daily Shows.

Saturday, April 03, 2010

Back to square one

NewFNP just returned home from her going away party held at the home of the medical director of the research clinic. She doesn't regret her decision to leave at all, but it sure as hell isn't easy.

Her last day was yesterday. Two weeks ago, she told a 29-year old guy that he was HIV+. She laid the foundation for his continued care, but she would like to have been there to help him. These are the situations that make working in health care so rewarding (helping people in their time of need) and changing positions so sad (leaving people in their time of need).

But on her last day, one of her favorite research participants who finished the trial several weeks ago, returned to the clinic.

"It's your last day, isn't it?" he asked newFNP. He came by to say thank you and to say goodbye. It was really touching.

And so she goes, back to urban community health full-time. Her NHSC loan repayment application is pending and she is happy to have regular hours, busy days and patients to care for.

But tonight, leaving the party, newFNP's heart is heavy. NewFNP loves people easily and there are some people at the research clinic who have won her heart. And she will miss working with them very much.