Broken safety net

NewFNP has no problem with HMO's. This is quite likely because newFNP is generally healthy, is in the know, and -- in true newFNP fashion -- has her primary care provider through one of the best medical groups in the nation.

When newFNP went to her PCP and told her that she has been having diffuse esophageal spasms for two years and finally thought it was high time to get that mother-effing upper GI and quite possibly some esophageal Botox, she received her referral before leaving the office and had a specialty appointment twenty minutes later. The system is connected and coordinated.

If, however, you are newFNP's patient and you have a state-insurance funded HMO and you need specialty care, you are jacked.

Take, for instance, newFNP's 31st patient of the day last Thursday. Three months ago, she was told at another clinic that she was HIV-positive. She was told to get HIV care. Where to get that care? Apparently that was not a part of the discussion. Thus, this 32-year old woman showed up at newFNP's clinic stating that she heard we did HIV care.

We do not. Yet.

So newFNP picked up her cell phone, dialed a nearby clinic and handed her phone to the patient who proceeded to make the appointment. Only that clinic doesn't take her HMO.

Son of a bitch.

Yes, newFNP could have gone through the regular old system of giving the referral to the referral coordinator who would get to it as soon as she could given the extraordinary amount of work that she has. Then she would mail the referral to the patient. But the patient wasn't "trying to get no mail from an AIDS doctor" so that option was out. And frankly, this woman had been wandering around for three months out of care and that is just not acceptable to newFNP.

The patient got all of the details regarding the insurance switch she would need to make and then spent some time talking to newFNP about how she doesn't want the HIV meds to make her crave drugs again, about how she can't get state financial aid because she committed a felony while crack addicted and then cried for her diagnosis, for her situation, for her frustrations. NewFNP listened, acknowledged, supported.

She left the room forty minutes later -- five minutes before the clinic was scheduled to close -- and was told by a member of the support staff and HIV planning team, "I thought you were taking care of this!" To which newFNP replied, "What the fuck do you think I'm doing??!" As though taking the time and providing the care to this woman was unacceptable.

NewFNP was livid. And then she went and saw patient number 32.

Hemoglobin of 6

For those not in The Biz, a normal hemoglobin in roughly in the neighborhood of 12-16 g/dL.  NewFNP is not going to lose any sleep over an 11 or even a 10, but she will assess your gender and diet and overall health and pregnancy status and miserable menstrual periods and history of hemoglobopathies, yada yada yada.  

No, newFNP doesn't go into real worry mode until she sees hemoglobins in the single digits and, really really not until it's below 9.  

But what will get newFNP's attention faster than a J. Crew shoe sale is a hemoglobin of 6.  And that is exactly what newFNP has seen this week.  

Twice.

NewFNP's first crazy anemic patient is the 30-year old with AIDS.  He came in noting copious frank rectal bleeding times four days.  NewFNP saw him two weeks earlier and his hemoglobin was 10.  NewFNP placed him back on iron and instructed him to return to his HIV doctor.  He is taking the iron but is less adherent with his HIV care.  Some might say that his priorities are askew, but when your hemoglobin is 6 and you are bleeding from your rectum, newFNP doesn't have that chat with you.  She examines your bleeding after 5 minutes of hemming and hawing over the embarrassment about showing newFNP your b-hole, notes frank bleeding and transfers you to the hospital for transfusion and diagnosis of etiology.  

NewFNP spoke with his nurse at the HIV clinic a couple of days after his admission- he's hospitalized, transfused and recovering.  But, in reality, he is circling the drain.  He's failing his HIV appointments and taking his medications incorrectly and not taking all his prophylaxis meds.  It breaks newFNP's heart to see him suffering so much and to see him not adhering to his care.  Thirty years old.

The second anemic patient this week presented to clinic with vaginal itching.  She is 14 years old.  She wasn't with her parents because she's sexually active and doesn't want them to know.  NewFNP got her history and was about to begin her exam when she realized that she had forgotten to look at the lab section of the chart.  She flipped back and saw that the patient's hemoglobin was 6.1.  She asked the patient about heavy periods or dark stool or nosebleeds - nothing.  She thought that the MA must have made an error and asked her to repeat the test.  It was 6.3.

This brings newFNP to another point.  Both times, newFNP's MAs had no idea of the significance the very abnormal result held.  One MA is known to newFNP and she's not entirely surprised, but when newFNP expressed shock at the result and instructed him to repeat the test, he was in the patient's exam room, repeating the test in a fricking flash.  NewFNP saw the second patient in a clinic that is not her regular site as she was filling in for a provider who is on vacation.  Unlike the MA at newFNP's regular site, this MA did not seem very impressed with newFNP's instruction to quickly repeat the test.  Frustrating.  But it does bring to mind a few lessons:

1. Repeat abnormal values.
2. Work with the same MA so that you can teach him/her abnormal values that necessitate your attention.  The same MA who blew newFNP off when she asked her to repeat the hemoglobin also let a post-CVA hypertensive woman sit in the lobby for two hours after having recorded a blood pressure of 198/110.  NewFNP was displeased.

NewFNP called the fourteen-year old's mother, told her that her daughter wasn't feeling well and had come to our clinic where we detected this anemia.  Her mother told newFNP that she was anemic because she didn't take vitamins or eat well.  Hmm, not the most common reason for a hemoglobin of six, but very motherly, no?  NewFNP told her that her daughter might need a transfusion and could she please come to the clinic.  

NewFNP's big worry is cancer.  She's not sure if she'll ever know what happened with this young woman but she doesn't have a good feeling about this one.  

He has AIDS

Truth be told, newFNP generally loves to be right.  It's not her best personality trait, but it is what it is.  She's working on it and nursing school certainly helps one learn how to say, "I was wrong."   

This is one case in which newFNP wishes she were wrong.  She had almost convinced herself that her patient was just seroconverting and that was why he had this malaise, this acute drop in immunocompetence.  As if all of her worry and her wishes and her day-off appointment coordination and letter writing could change the course of the pathophysiology at work throughout this young man's body.

But newFNP got her CD4 count today.  It showed his absolute CD4 count as less than 20.  His percentage of CD4s was three.  The low end of normal is 20%.  NewFNP's heart broke.

This patient has really touched newFNP.  It is probably for his loneliness, his isolation.  NewFNP has always been drawn to these people and has always wanted to show them that there is someone in this world who cares for them.  This is perhaps a result nature (newFNP is what she is) and nurture (losing her mom at a young age and all its subsequent emotional detritus).   Whatever the psychoanalytical insights, newFNP is willing to go the extra mile for these people.

It is probably also because this patient knows that newFNP is there for him and newFNP knows that he knows that he can count on her.  Today he told newFNP that she was the only one to visit him in the hospital and that he never feels shame when he sees newFNP.  NewFNP knows that he is keeping his diagnosis from the majority of people in his social circle so it felt good to hear that he felt cared for by newFNP and her staff.  He gave newFNP and her MA heartfelt thanks and a warm hug as he was preparing to exit the exam room.

Which was where the hug-fest ended and the pissed off newFNP began.  Her lab MA refused to draw his blood.  If he would have refused in front of the patient, newFNP would have stroked out.  Thankfully he had the good sense or good luck to refuse while the patient was still in the room.  He knew that the patient was HIV-positive because newFNP didn't want the patient exposed to all of the ill people in the clinic until he is on PCP prophylaxis and ART.  Therefore, newFNP's MA asked him to either clear the lab or draw the blood in the room.  

NewFNP is in a quandary.  She supposes that an MA may refuse to do a task.  But can the lab MA refuse to draw blood?  We have and use universal precautions for a reason.  We treat all patients with dignity and we treat all of their blood as potential pathogen-carrying fluid.  So how does newFNP approach this?  Education, newFNP supposes.  But she is just so pissed!  Is de-stigmatizing HIV only an activity for educated people?  God, newFNP hopes not.  We need some ACT UP in the lab!

Furthermore, why was this man discharged from the hospital without PCP prophylaxis and an appointment with an HIV specialist?  NewFNP is awaiting the hospital records, but is pretty frigging disappointed that he left only with a repeat prescription for his original fungal infection. Is it possible that the hospital staff chose to ignore his HIV status and not at all assess his immunocompetence?  Is that the care newFNP can expect when she sends her patients there?

More and more, newFNP is missing real public health.  She is missing the sense that her work is saving people, is preventing illness.  NewFNP is generally not to full of self-inflation, but she didn't go into healthcare to diagnose HIV when it is actually AIDS, to diagnose diabetes when it has already impacted eyes and kidneys and feet.  

It is so sad, so utterly disinflating.

NewFNP left work an hour after the clinic closed tonight.  She relished the only quiet time of her day as she made the abnormal lab list, she wrote a couple of e-mails that she hadn't been able to get to earlier in the day and she updated this patient's confidential HIV report, noting his AIDS-defining CD4 count.

She feels like shit tonight.  Calorie restriction be damned!  Ice cream, anyone?

Home sweet home

NewFNP has just returned from a glorious long weekend with her graduate school pals. She ate good food, hung out with her friend's kids - one of whom called her Frank Gehry fish necklace a 'banana phone', drank too much wine and shopped in a very hipster area of an across-the-county metropolitan area.  It was a great weekend and newFNP misses her dear friends already, but it sure feels lovely to cross the threshold into one's own apartment.

Before newFNP departed, she checked in at the hospital where she had transferred her HIV+ patient.  He was admitted for presumptive PCP and was still spiking temperatures.  He was set to receive a blood transfusion for a hemoglobin of 7.2.  He was in isolation due to concern for TB.  

This is the guy that the paramedics gave newFNP a hard time about?  One of the paramedics actually asked newFNP, "Well, did you listen to him?" when she told him of her PCP suspicion. No, dickhead, newFNP makes it a practice to not examine her patients prior to calling for EMS. The vast majority of the paramedics are so great and sort of participate in the group effort we all undergo to attempt to keep our patients well/alive, but this interaction brings to mind another frustrating experience with EMS.  Last time, the asthmatic kid was admitted for several days.  This time, her patient is still in the hospital.  She talked to his nurse this morning.  IV Vancomycin Q8 hours and still spiking temps.

NewFNP wishes that she wasn't right about this one.  But she also doesn't want to have a fight in the hallway with the stubborn paramedic.  NewFNP - believe it or not - is trained to make decisions such as when to send patients to the hospital and she doesn't want to duke it out in the hallway.  And, with this guy, she got the distinct feeling that he just wanted to blow off the transport and make a point of questioning newFNP's judgement.  Is it possible that he didn't want to transport someone with HIV and a fulminant facial rash with a suspicion of AIDS?  NewFNP hopes that is not the case.  She would much rather have him think that newFNP is a big fat idiot.  

NewFNP wishes that she knew more about HIV management.  Of course, newFNP would not be able to provide such services in her clinic without social work and drug assistance and support for remaining clean & sober.  Nonetheless, newFNP feels like her HIV management knowledge hits an abrupt wall soon after diagnosis.  Perhaps a good CME topic.

Seriously... again?

NewFNP really wanted to do primary care.  She wanted to be out in the trenches, preventing diabetes and HIV and obesity and the like.

What a fucking sucker newFNP was.

In newFNP's clinic, there is a paucity of true primary care.  There are many reasons for this, not the least of which is that newFNP's patients come in the the clinic already sick.  NewFNP spends as much time putting out fires (read: lowering>500 blood glucose) than she does educating diabetics about the pitfalls of the all-carb breakfast.

But newFNP's clinic is also lacking in early intervention.  It's like the frigging uncontrolled disease rodeo and the providers need to lasso those buckaroos back into control.  It sucks.

Today's case in point.  Last week, a 31-year old man came in to see newFNP with what newFNP determined to be a diffuse cutaneous tinea infection - essentially covering his face - and a 23-pound unintentional weight loss over the previous five months.  Although he denied HIV risk behaviors, newFNP tested him.  

When his result came back positive, newFNP attempted to reach him by phone to get him back into the clinic.  It has been an ongoing struggle for our front desk staff to remember to ask for updated contact info and this was one patient whose new phone number slipped through the cracks.  NewFNP felt horrible in learning this.  How in the world would she contact him and get him into treatment?  How could she have let public health down and not updated his information herself?

Fuck that, newFNP decided.  She grabbed her clinic manager and walked the five blocks to his house today.  Pretty much every staff member that heard of her outreach plan looked at her as though she had utterly lost her mind.  One asked if she was bringing a gun with her.  She did not.  She knew that the address may not have been correct, but she needed to fill out the HIV case report and thought it best if it was completed to the best of her abilities.

Now, newFNP works in a metropolitan center that is rather renowned for its urban blight.  She is generally so busy that she doesn't leave the confines of the clinic during her work day.  But today she ventured out and really saw what all the fuss is about.  Sure, drive by shootings and gang warfare get all the press.  But what the fuss is about is a lot of loafing and mid-day drinking.  Perhaps, on a larger scale, one might say that this fuss is about unemployment and bleak future prospects, but newFNP has been so damned heavy lately - she just can't go into all that.  She, thankfully, was spared the gang-related drive-by shootings.

As she walked those five blocks, newFNP was struck by how an eleven mile drive really transports newFNP into a whole different world.  When newFNP hits up the liquor (OK, wine) store, she rarely - if ever - sees groups of people hanging out or talking on pay phones, all the while with their toddlers in strollers drinking extra large juices or their school-aged children decidedly not in school.  When she has a weekday off and walks to the store, it's rare that she sees groups of middle aged guys just lounging on the front lawn, shooting the shit and drinking Budweiser tall boys.

But that is exactly what she saw as she walked up the street, clinic manager in tow, and cautiously approached the address listed on his chart.  NewFNP's clinic manager inquired as to the patient's whereabouts, to which one man replied, "You mean the guy from Honduras?"  Hmmm... that is not information with which newFNP was armed.  Another guy said, "Oh, you mean the one with the spots on his face?"  Bingo.

According to the Budweiser posse, he did not in fact live at the house, but across the street. One gentleman offered that newFNP's patient was cooking in the back and went off to retrieve him. The men told newFNP that there was a point during which her patient could hardly get out of bed and they wondered what was wrong with him.

It's safe to say that her patient was surprised to see her.  She asked him to come with her the clinic and he agreed to be there a couple of hours later.  When he arrived, this 31-year old man's temperature was 103.1.  His lungs were junky - wheezing and rales.  His O2 sat was 96%.  

Not only did this guy learn of his HIV+ status today, he was transferred by ambulance to the hospital to rule out pneumocystis carinii pneumonia, an AIDS defining diagnosis.  

It was a heartbreaking appointment.  He lives alone.  His entire family is in Honduras.  He has no phone.  He has been clean and sober for a mere six weeks.  He told newFNP that it would have been better had he never known, that he would be better off dying.  

NewFNP told him about the advances in care and medications, about the many services available to HIV-positive people in this huge city, about how he has the resources, albeit limited, of newFNP's clinic to support him.  But newFNP knows that this is a socially isolated, marginally literate, extremely poor man whose social circles may be more likely to shun him than to support him.  Honestly, newFNP is as concerned with his emotional well-being as she is with his physical.

And, for the second time, newFNP gave an HIV+ test result not when the patient was generally well and had natural defenses intact, but when the patient was ill.  When they likely had AIDS at the time of their diagnosis.

That is not right.  It's not right.

Shit.

When newFNP last wrote, she noted that she had disclosed to a patient that she was HIV-positive.  NewFNP was wrong.  

She has AIDS.  

When newFNP told her patient that she was HIV-positive, her patient asked, "Does that mean I have AIDS?"  When she asked, newFNP knew that AIDS was a possibility.  NewFNP replied that she would know more when she got the rest of the blood-work back.

Her CD4 count came back today at 166 - an AIDS defining number according to the 1993 AIDS Surveillance Case Definition of the CDC.  NewFNP had a shit fit when she learned from the lab that the viral load was submitted incorrectly and could not be determined.  It matters and it doesn't.  The CD4 count is in the toilet, the patient is smoking crack and drinking on a daily basis and newFNP can't reach her.  She can't start on anti-retrovirals anyway - you don't want to have a patient fail her first, and best, option and - frankly - active debilitating addiction is not an ideal starting place for HAART if one is looking to prevent resistance.  

The situation is, pardon newFNP's French, fucked.

NewFNP wrote the prescription for Bactrim for PCP prophylaxis and attempted to reach her patient in order to get it started.  Of course, being precariously housed and without a phone, newFNP could only leave a non-specific message on her patient's friend's cell phone.

NewFNP's patient did not show up in clinic today to pick up the prescription.

NewFNP's passport is out and her dollars are exchanged as she is heading out for a longer long weekend in a far-away land.  But newFNP's patient will weigh heavily on her heart while she is away.

So, so sad.

End of the day blues

At the end of the day, newFNP likes the following types of patients: medication refills; normal lab results; well-child visits with vaccines already up to date; hell, even an uncomplicated UTI is fine!

But a blood pressure of 190/110 in room 4 and an as-of-yet undisclosed HIV-positive drug addict/alcoholic in room 5?  At 4:30?  Unacceptable.

Unacceptable and sad.

Again, newFNP will counsel that resisting the lure of daily crack and malt liquor use, coupled with exchanging sex for money and drugs, is a step in the right direction if one is interested in preserving one's health.  

But, even though newFNP's patient knew that she had engaged in some risky behaviors in the past, that did not make it any easier for her to hear the news.  This 6-foot tall, 130-pound woman who smelled strongly of booze sobbed, her face in her hands and her skinny body slumped on the uncomfortable plastic seat in the exam room.  

"Is that why I can't gain no weight?" she asked newFNP.  Could be.  But maybe the daily crack use has something to do with that as well.  Just a thought.

NewFNP frequently uses "we" when she is discussing sub-ideal behaviors with her patients, a la, "Sometimes when we are emotionally distressed, we gorge on mango Mochi" or "Sometimes we over-do it on shrimp dip during the holidays."  Nonetheless, when her patient asked why this was happening to her, newFNP was somewhat surprised to hear herself say, "Sometimes when we have a serious addiction, we trade sex for drugs or money and don't use condoms."  That elicited a nod of agreement from her patient and, truthfully, a little internal chuckle in newFNP.  Yeah, survival sex has played such a big role in newFNP's life.    

NewFNP did her patient's exam: lungs clear, heart regular, nodes everywhere, pap pending.  She drew lab work: CD4, viral load, RPR, heps AB&C, toxoplasmosis IgG, CMV IgG.  She gave her referrals to HIV clinics.  She encouraged her to attempt sobriety.  

It was a tough encounter for newFNP.  She wanted to handle this one right, to be a voice of support and caring in the life of a woman who has clearly lacked these two things in the past.  NewFNP thinks that she achieved that, but it is kind of hard to tell when your patient is drunk, probably has some underlying mental illness and is devastated.

Oh, and newFNP got the other patient's BP down to a marginal 146/95 and sent him on his way with three BP meds and a follow-up appointment.  It sucks to have to have given pretty decent care to one patient to the detriment of the other patient.  Both patients have potentially deadly conditions, both are rather poor at compliance, but only one got a full 45 minutes of newFNP's time.