Stirrup fail

It is preferable that when new patients come to the clinic, newFNP is (A) on time, (B) fashionable and (C) attentive. Thanks to her super cute new not-even-on-the-website-yet JCrew top, she was quite fashionable. Thanks to her caring nature, she was attentive. On time, however, remains an elusive trait for newFNP in her professional life -- ironic in that newFNP is pathologically early in every other aspect of her life.

So, all in all, two outta three. NewFNP will take it.

The appointment was moving along as smoothly as a newly threaded brow when newFNP attempted to extract the stirrup from its in the table hiding place. The stirrup gave newFNP a little resistance. Not to be deterred, newFNP gave it a little tug. Nothing. Determined to get the best of the stirrup, newFNP pulled at it with a little force.

And that is when the entire fucking stirrup came out of the table and into newFNP's hand. Imagine her surprise! She felt somewhat like the Statue of Liberty carrying her torch as she walked around the clinic, folded stirrup in hand, attempting to find her MA both to share with her the craziness of our clinic environment and to have her help newFNP replace the errant stirrup. Give newFNP your tired, your poor, huddled masses yearning to breathe free -- and to have their pap tests with intact examination tables.

NewFNP not so gently maneuvered the stirrup back into place and with the snap of broken plastic, shifted the stirrup, and subsequently the patient, into position and continued on with the exam.

Bienvenidos a nuestra clinica de la comunidad!, newFNP told her patient, who was kind enough to laugh.

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.   

Three-peat

Would anyone believe newFNP if she were to tell you that the power went out yet again at clinic today?  True story.  Although to look at the patient population and to hear the language spoken, one might think that they had taken a wrong turn and ended up in - say - Mexico or Guatemala with their associated electricity issues.  One would, however, be mistaken.  

Several of the flashlights from the outage less than two weeks ago went AWOL, the generator arrived yet filled the halls with the unmistakable scent of gasoline, sending the dental director into an asthma attack and yet, newFNP and her colleagues, including the podiatrist, continued to see patients.  

Want that toenail removed?  Bring your own flashlight!

The return of Cocoa Brown

Just when newFNP was thinking that she was running out of stories to share, the elusive Ms. Cocoa Brown returned to the clinic!

NewFNP walked into clinic this morning with a spring in her step and noticed Cocoa's best friend sitting in the waiting room. She was not hard to miss, what with the 250-something pounds and the bright yellow sweater and shorts ensemble. It wasn't until she had almost entered the back office did she hear Ms. Cocoa Brown call her name.

"Hi newFNP!" she cheerily sing-songed. Now, newFNP has been trying to get in touch with her for months in order to follow up on that pesky syphilis. It's always, "Tomorrow - I'll be there tomorrow." Thus, newFNP gave Cocoa a look that said both "finally" and "where have you been?"

"Don't be mad," Cocoa told newFNP, "I've been in jail."

NewFNP can hardly think of a better excuse by which to deflect one's accountability for n0t making it to one's clinic appointments than that of incarceration. Apparently, the felony warrants and copious tickets were too heavy a burden for Cocoa and she turned herself in.

And now here she was, by her accounts sober except for the occasional Bartles & James wine cooler, which - in her estimation- have no alcohol.

While newFNP was addressing the need to re-check an RPR to monitor titres, she had her MA move Cocoa's hypertensive pal into another room to perform a screening EKG. A different MA tried unsuccessfully to draw Cocoa Brown's blood. NewFNP twice tried unsuccessfully to get blood from her tiny veins. A third MA took a break from setting up the EKG to give it a whirl, also to no avail.

Cocoa Brown graciously offered to return to the clinic for her venipuncture another day, but newFNP was having nothing of it. Yes, it is a torture, but frankly, obtaining that blood sample was a high priority. NewFNP sent her to hydrate and she opted to do so in the room where her buddy was having her EKG.

Fine.

It was at this point that the power went out.

NewFNP's MA, Cocoa Brown and her half-naked 250-pound friend were all in the exam room, Cocoa Brown with her two glasses of water, her friend with her paper gown and EKG mid-way completed and newFNP's MA wondering what in the hell to do.

NewFNP's chronically late but exceptionally gifted MA/phlebotomist finally showed up. NewFNP sent her in with a flashlight and a butterfly to get the sample.

Success!! Winnie the Pooh sticker in hand, she left the clinic with instructions to return in two weeks. Anyone in a gambling mood?

NewFNP continued to see her patients, flashlight in hand, until about 2:30 PM when the power was restored. This is the second time in as many months that newFNP's clinic has had a power outage due to a downed power line. The first time they sent us home after several hours. This time we had flashlights. NewFNP hears that a generator is in the works which, of course, the clinic needs, but damn it if newFNP doesn't appreciate a little unexpected light day every once in a while.

T.G.I.F.

NewFNP loves her Fridays off. A little hiking, a little Bloomingdales sale to spend birthday 2006's gift certificate, a little Cosby Show rerun*. OK, that part is not so great but newFNP is one of the few remaining people who do not have cable so she is willing to indulge in a little retro-TV for a half hour.

She has spent a fair amount of her free time today, however, wondering what happened with a kid she sent to the ED on Wednesday.

NewFNP is generally so overwhelmed with type 2 diabetics that she had almost forgotten that type 1 diabetes existed as well. She even expects to diagnose her pediatric patients with type 2, given the degree to which she encounters the consumption of Hot Cheetos, Gatorade, and whole milk in her patients, as well as the prevalence with which she notes acanthosis nigricans, abdominal striae and hidden penises on physical exam.

However, newFNP would be remiss if she forgot that those wacky type 2 patients account for only 90% of diabetes diagnoses. She is fairly sure that she caught a kid in the early stages of Type 1 this week.

What a lousy 10% to be a part of!

This normal weight twelve year old boy -- whose well-child visit and urine dip were unremarkable a mere six months earlier -- came to our clinic with the chief complaint of abdominal pain. NewFNP's list of differentials includes things like appendicitis, AGE, UTI, nephrolithiasis and post-Winter Break school avoidance. As a general screening tool, newFNP has impressed upon her MA the importance of obtaining a urine dip on all of her tummy ache complaints and her MA never fails her in regards to this task.

Well, imagine newFNP's surprise when this kid's urine was chock-a-block full of glucose and ketones! When newFNP checked his fingerstick glucose, it was 313 and this was not a kid who had fed at the fast food trough prior to his visit. He had lost 3 pounds since his last well-child visit. He didn't look bad, just a little tired. He didn't smell ketotic and his breathing was normal.

NewFNP hasn't seen type 1 diabetes since she was working as an RN in her training hospital. She hasn't diagnosed it before and she was not sure if this kid's abdominal pain had anything to do with his diagnosis. Well, as it turns out, acute abdominal pain is a common presenting symptom of type 1 diabetes. Huh!

NewFNP's clinic has nothing - no RN's, no health educators, no nothing. Therefore, some quick education with the kid and parent about newFNP diagnostic suspicions and off to the ED. NewFNP is hopeful that the patient will bring back such important paperwork as c-peptide test results, discharge instructions and the name of his endocrinologist.

And if he comes back in tomorrow, newFNP will be waiting there for him at seven-fucking-thirty. She will make every effort to be pleasant, but it does, frankly, seem a stretch.

* In this episode, Rudy gets sent home by the school nurse when she gets her first period and Claire wants to have something called "Woman's Day" with her. Apparantly, Lisa Bonet and the other daughter - Vanessa, if memory serves - both had Woman's Days and Vanessa's involved a trip to the Plaza Hotel for brunch. NewFNP went to the Plaza to celebrate her her 30th birthday, not her frigging menarche, a day which she still curses! Those crazy Huxtables!

Yeah, you're in the right place.

NewFNP recently had a conversation with a good pal from grad school, BostonCNM (not to be confused with although currently and temporarily co-habitating with BostonFNP). BostonCNM has recently changed practice sites from a cushy suburban practice with an educated clientele committed to a midwife assisted birth to a ridiculously busy community health center in a wrong-side-of-the-tracks area of Boston.

There is something deeply validating about sharing the experience of working in a completely fucking disorganized setting, yet loving the work that you do -- and bitching about it with one of your BFFs.

It started newFNP thinking about how one might truly know that they are working in urban community health. What are the requisite community health bona fides? NewFNP will share them with you.

1) In general, your patients will not speak your primary language. Their language might have no written form or may consist of clicks, thus making them impenetrable to an otherwise educated and teachable person. You may perhaps speak the language, but that would mean that you or your parents had acumen which started you off on the Spanish language path at an early age. NewFNP's mom had that insight. Sadly, newFNP was both intransigent and snobby and insisted, at the age of eleven, that she would speak French. While this proved quite helpful during her Tahitian vacation at the age of seventeen, it has proven itself much less so in the years since.

2) You will run out of crucial supplies. These may include but are by absolutely no means limited to: specula; lead testing strips; table paper; otic thermometer probe covers; patient drapes/gowns; charts; and medications. Furthermore, you will discover that these supplies are missing at inopportune moments, such as when your patient is in the lithotomy position, covered with paper towels and with two serving spoons fashioned into a speculum by the ingenious placement of folded cardboard and a rubber band in lieu of the real deal.

3) You will care for patients who have absolutely no idea how to care for their health. You will feel astounded at this. This feeling will not go away.

4) Your patient no-show rate will be in the 50-70th percentile. Therefore, your front desk staff will bring in tons of walk-ins. And then, one day, your no-show rate will be 10% but they will still let in the walk-ins. On those days, you will be fucked.

5) You will work with people who frustrate you and who could, at times when one is feeling less than generous, be considered incompetent. NewFNP has noted this before, but believes that because it is so intrinsically linked to community health practice, it is worth noting anew. See Office Staff Rant for a more thorough investigation of this phenomenon.

6) You and your co-workers will have more than one job. Medical assistants double as referral coordinators. Admin assistants place the orders. Providers do everything. NewFNP makes copies, fills out a trillion forms, writes letters and fields phone calls from senior management asking about this or that. This does not lead to efficiency, nor does it lead to satisfactorily completed tasks. Moreover, it may contribute to job dissatisfaction.

7) You will have crazy stories to share with your pals who work in law or fashion or business. You will frequently hear phrases such as "No fucking way" or "What the fuck?!" or "Jesus, how long do you have to stay there?" when you recount these stories.

8) In the end, goddammit, the goods will outweigh the bads and you will feel good about your work at the end of the day. But not so much in the morning when you see the line snaked around the block as you walk into another day of 10-15 minute appointments.

Holiday! Oh yeah, oh yeah! Celebrate!

Ah, the joy of a two and a half-day weekend! NewFNP did have to work on Saturday but then was able to luxuriate in the glory of 2.5 days off. That is, until she attempted to return to work this morning and appreciated the hell that is the first day of school, which added a full 15 minutes onto her usual 20-25 minute commute, only to arrive to a waiting room with a population density that rivaled Calcutta.

It is entirely anecdotal yet positively indisputable that the first clinic day after a holiday weekend sucks donkey nuts.

Too. Many. Patients.

What happens in that one extra day during which newFNP is having brunch and playing Scrabble and cursing The New Yorker for not picking her brilliant caption that causes a 15 billion-fold increase in patients?

And the air conditioner in newFNP's clinic has bought the farm. Granted, that was two weeks ago but temperatures are soaring here is newFNP land and one would not call the exam rooms in newFNP's clinic 'spacious' or 'windowed,' thus creating a real issue with heat, smells - you get the picture. Perirectal abscess? Sitz baths and Keflex until the air conditioner is repaired. Not that newFNP would do that, but it seems a fair alternative given the conditions.

All in all, today was almost enough to make newFNP seek refuge in the suburbs. Or the spa. Or Barney's. Or perhaps just the H.M.S. Bounty.