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.

Bring it.

There are times in everyone's role transition in which they wonder if they are, in fact, cut out for the career they chose.

NewFNP had several such instances in which she thought - whoa pal... perhaps law school.

The first involved a patient who had a horrendous necrotic pressure sore that was so deep, it almost exposed the bone.  This woman also had MRSA which meant that all staff were on contact precautions which, in newFNP's training hospital, consisted of a mask, gloves and a plastic gown.  

It was the end of the day's rotation and newFNP had been busy as hell.  She hadn't eaten.  She was tired.  And the smell of that pressure sore plus the tenting of the skin as the physician cut away necrotic tissue plus newFNP's hunger plus the millions of people in the room causing increased temps (and smell) plus the plastic precautions gown equaled newFNP sitting on the floor with her head between her knees in an attempt not to pass out.

A successful attempt, but clearly not a shining moment in student nursing history.  

Another involved a patient who had undergone a partial pneumonectomy and, for reasons that now escape newFNP's memory, had failed to heal well.  As a result, he had what is best described as a gill-like slit in his side that moved in a gill-like fashion when he breathed.  And in that gill-like slit, there were strings of mucous that would quiver during respiration.  

The vivid recollection sends cold shivers down newFNP's spine.  

NewFNP left the room and told her preceptor, "I don't think I'm cut out to be a nurse" to which her preceptor raised one eyebrow - her way of saying that she disagreed.

NewFNP wrote about another unsatisfying olfactory experience three years ago.  NewFNP recalls feeling so disheartened.  How on earth would she take care of her patients if she could not even observe this procedure and remain on her feet? she wondered.  NewFNP's consulting physician attempted to console her by confirming that that was, in fact, a hella smelly abscess but it didn't really make newFNP feel much better.

NewFNP has come a long way, baby.  In these past three and a half years, newFNP has incised and drained her fair share of abscesses, but for the past year, the abscesses had dried up.  

Until today.

When newFNP hasn't performed a procedure in a while, she feels a tad apprehensive prior to embarking upon one.  Especially when it involves a scalpel and lidocaine and inflicting pain.  But the beauty of having a few years under one's belt is that it all comes back to you when you need it.  For better or for worse, even the inflicting pain becomes easier in one of those you've got to be cruel to be kind kind of ways.

And - gross though they may be - procedures are kind of fun.  They are so much better to perform than to observe.  In the case of an abscess, the results are immediate.  The smell doesn't seem to bother newFNP so much when she is doing the cutting, expressing, irrigating and packing.  

In fact, she wonders how her MAs are such tough asses in their assisting whereas newFNP has near syncopal episodes.

NewFNP is ready for more!  

Again, for those struggling students out there, it's worth it.  You'll be ready, too.

Thanks, buddy.

There are aspects of any new NP's experience that are less than savory.  These may include the retrieval of a malodorous weeks-old feminine hygiene product from a vagina, the careful examination of moist fungal foot lesions or the olfactory assault during the always enjoyable abscess incision and drainage.  

NewFNP wouldn't say that she would opt to participate in any of the aforementioned activities, but she is aware that certain complaints require certain assessments.  For instance, if you tell newFNP that your ear hurts, you can bet that she will check out the affected ear(s) as well as the associated lymph nodes and she'll throw in a oropharyngeal exam at no extra charge.  If your va-jay-jay has taken a turn for the worse, newFNP will have you in the lithotomy position as fast as you can say "wet mount."

And if you tell newFNP that your prostate is acting up, that you're having decreased urinary stream and that it hurts to ejaculate, newFNP will think, "Crap - prostate exam" -- no pun intended.  

When newFNP informed her patient that he was soon to be intimately acquainted with her gloved finger, he told newFNP that he would rather not.  NewFNP, somewhat relieved, stated that she would draw the PSA and, if abnormal, would conduct the DRE.  He seemed dissatisfied and told newFNP that, if she wanted,  he would consent to the DRE.

If she wanted??

Honey, when it comes to prostate exams, want does not come into it.  Begrudging acknowledgement of necessity, yes.  Desire, no.

As if a prostate exam was all newFNP needed to have the perfect day.

Burn baby, burn.

NewFNP's clinic has had a spike in the incidence of STD's lately. Since Cocoa Brown, two more patients have tested positive for syphilis. Neither of them were Ms. Brown's abused partner. Another patient's downstairs was so disturbing in the olfactory sense that newFNP was quite sure that an animal had crawled up there, homesteaded her vagina and died.

And, finally, newFNP has been burned by chlamydia twice recently. Thankfully, the burn has only occurred in her professional life!

Chlamydia is supposed to be asymptomatic at best and have a mild discharge at worst. It is not supposed to mimic gonorrhea and have purulent discharge and a traumatizing odor. NewFNP fully acknowledges that she is at fault here in that she should have treated the patient for chlamydia when she erroneously treated the gonorrhea. But the discharge, people, the discharge. Who could have thought that little ole chlamydia would cause such a thing?!?

It sucks to have failed public health to re-learn the lesson that you treat for chlamydia when you treat for gonorrhea. But here newFNP is, kicking herself for missing the Chlam.

Let this be a lesson to you, newFNP readers. Be liberal with your STD antibiotics.

Judiciously liberal, of course.

The saga continues

Cocoa Brown is fucking crazy.

When newFNP returned to work and asked Dr. Dual-Ivy-League-Degrees if Cocoa had returned to clinic for her syphilis treatment, she stated that she had and proceeded to recount a story that put Cocoa Brown into a special kind of crazy league. NewFNP is not talking about the kind of crazy that causes you to feel that it's appropriate for your BFF to check out your herpetic labia or the kind of crazy that remarks con gusto about vaginal odors. No, this is a new kind of crazy.

One might call this kind of crazy "felonious."

Apparently, when CB learned of her multiple STI diagnosis, she confronted her new partner, a wise and responsible move all in all. That is where wisdom and responsibility end and crazy as fuck enters. CB's partner, upon learning of her HSV infection, informed her that herpes was not likely to be the only infection that she had and that she had better check in with her doctor.

At this point, Cocoa Brown understandably lost her shit. Who wouldn't? One would assume that words such as "motherfucking asshole shitlicker" and "son of a bitch piece of shit no good dog-humper" would be employed, that voices would assume a fever pitch, that the sensation of imminent explosion resulting from extreme anger would be palpable.

One would not expect, however, that Cocoa Brown would attack her disrespectful partner with a 2x4 that had exposed nails with such vigor that he was hospitalized, but that is in fact just what happened. According to newFNP's colleague, she seemed not at all disturbed by this.

CB went on to explain to Dr. Dual-Ivy-League-Degrees that she had previously been incarcerated for prostitution and "other things." What could those be, newFNP wonders? Aggravated assault? Assault with a deadly weapon? Jaywalking? Furthermore, Cocoa is apparently treated for mental illness.

Just a hunch, here, but newFNP thinks that she might need a med adjustment.

You never forget your first

It's true for any number of experiences. First kiss, first love, first bad grade (not that newFNP would know anything about that), first abscess I & D. Now, let me go on the record as having stated that newFNP likes gross stuff. But what newFNP does not like are gross smells. Seriously. NewFNP has never eaten ketchup because she is repulsed by its aroma.

Here is the sequence of events:

12:30 patient: mucopurulent cervicitis
12:45: lunch
1:15 patient: abscess

The smell. Holy shit, the smell. First of all, it was an ass abscess. Top of the rump, right gluteal fold. Second of all, there were 5 of us in the small MF-ing exam room. Me, the patient, her sister, the super-MD I work with, and my favorite MA who lives for nasty procedures. Again, the room is small. The room was also hot. And did I mention the stench of the abscess? Can you see where this combination of forces leads?

So, prep, anesthetize, cut, express, express, express, express, express (you get the idea), whiff, feel faint, get hot and clammy, realize you are about to hit the deck, call for back-up, sit, regain composure, express, pack, cover. Try to get the smell out of your memory. Try harder. Keep trying. Visualize the relative beauty of the cervicitis. Thank the heavens for bullshit URI appointments.

And a tip: for those who are also new to abscesses, my MD told me that the pH of the pus weakens the effect of the lido so numb 'em up somethin' good! Happy draining!

Don't send me back

There are days when newFNP is simply unable to dodge all the shit being thrown her way. Today, of course, was one of those days. From 10 AM on, I had nothing but problems. Here they are.

One. Depression followed by PTSD. The depression was just sad. The PTSD, on the other hand, wasn't entirely convinced that he wanted to live. Clearly not an easy appointment. At least now I know how to write a 'safety contract' in Spanish. Oh, and when you are telling me that you think you'd be better off dead in one sentence, the next sentence sure as shit had better not be 'why do you think my throat hurts?'!!

Two. Hi, my new diabetic patient. I see you are 39 and have already had a below-the-knee/above-the-ankle amputation. I see that your burn wounds, affecting both hands, are not healing after 1 month, are slightly smelly although not infected and that your sugar is 'HHH.' Oh, you say you're peeing all of the time and that your vision is blurry? I can't say that I'm shocked.

Diabetes. Damn! Did everyone read the special in the NY Times about Spanish Harlem and the 20% prevalence of Type 2 amongst the residents there? Read it. It actually gives some good insight into how people cope (or don't) with the illness.

Three. It's 4:35. You're my 55-year old 3:30 complete physical and pap. It's not your fault that you're in my room late. I'm sorry you had to wait for me. Blame it on the diabetic guy.

Four. Prescription nightmare. Not my fault, but my mess to deal with nonetheless.

Five. My two incorrectly scheduled pediatric physicals, both scheduled at the same time, both 30 minutes late. Yes, your mom was pissed. I'll tell you what: next time be on time or call and let us know that you're late. Don't tell the receptionist that you didn't know you had to be on time. Have common sense and don't be mean to the front desk staff. This happened while I was with the patient who wanted to die, trying to get the social worker on the phone. So, no, I won't leave my patient to explain to you why I'm not seeing you today.

Is it any surprise that I cannot remember the other 18 patients I saw today? None of them were really 'easy,' many of them were new.

As I looked at charts in the hall before entering the patients' rooms, I was very conscious that I had to keep my frustration with my day to myself. I had to tell myself that Sra. X deserved the best of newFNP, not the frazzled and borderline tearful newFNP. That is a tactic I haven't had to employ frequently, but it was indispensible today.

And, thankfully, it worked. Yes, I was miserable with stress. Yes, I thought of requesting a phenobarbital-induced coma. Yes, I was thinking of ways to avoid ever going back to work again as long as I live. But I treated my patients well at the end of the day.

Even the one whom I saw at 5:15.