Hit me with your best shot

NewFNP has had better days at work.

To begin with, newFNP's back is jacked up and she is walking like she has a stick up her ass. Then she saw 17 patients before lunch.

Then her last patient hit her in the face. Open hand, but with the force of 202-pounds of mother-fucking crazy behind it.

NewFNP has never, ever been hit before. She is a white girl from the suburbs who went to top tier schools and watches Jon Stewart and goes to spin classes and shops at J. Crew. She does not engage in fisticuffs. And, quite frankly, she could go the rest of her life without ever being hit again if she has her way. It hurts. NewFNP was actually dizzy. And she was completely fucking shocked.

After her patient was forcibly removed from the clinic 5150-style and newFNP spoke with the officers about her being a victim of battery (not her words, but noted on the very official police report), she was told that she should go home for the rest of the day.

No shit.

It's one hell of a way to get half a day off, but you don't have to tell newFNP twice to get the hell out of dodge. Why couldn't her patient unleash the crazy at 9 AM instead of at 12:30??

Psych!

NewFNP sees a lot of mental illness in her practice, but it is mostly dysthymia and depression. There have been a couple of wildly positive Mood Disorder Questionnaires, of course, which are generally accompanied by such wild extremes of dress that conducting the MDQ seems almost superfluous.

But it is really rare for newFNP to see schizophrenia in her clinic and it is really, really rare for her to have two schizophrenic patients on the same day.

NewFNP's first schizophrenic patient of the day was a G15P9 three-hundred pound crack-smoking schizophrenic with no teeth who lived in a board and care. She needed a pap and an HIV test which, you gotta hand it to her, is pretty decent self care for someone who is really deeply troubled. She had been off of her Seroquel for a few months and her flat affect was remarkable. NewFNP has never had so many monosyllabic responses to questions, even on her worst of dates. But it wasn't her negative symptoms that had newFNP concerned. NewFNP asked her of she had been hearing things that others could not hear.

"No," she responded.

NewFNP then asked if she had been seeing things that others could not see.

In the flattest of voices, with no change in tone whatsoever, she replied, "Last week the shadows came back."

The way in which she replied was so freaky and the response itself so fucking creepy that newFNP just resumed her Seroquel rather than having her wait for her psychiatric appointment.

Later in the same day, everyone's favorite schizophrenic patient, Cocoa Brown, came back to clinic for a follow up appointment. She, too, was smoking crack, had horrible dentition and approaching three-hundred pounds. Her weight had increased 24 pounds over the past month. She felt uncomfortable and wanted pain medication.

"Can't you give me some Tylenol #3s?" she asked newFNP.

"No."

"Some #4s??" she tried.

"No."

Her lower extremities were edematous. She was experiencing orthopnea. NewFNP's heart sank as she told Cocoa Brown that she was concerned about heart failure. She wrote some prescriptions and, not wanting her to go AWOL as she is wont to do, exited the exam room with her to accompany her to the lab.

As she walked out the room, newFNP's colleague - a good-looking Cuban doctor - told her hello. She smiled, giggled and said in an unreasonably loud voice, "He's handsome!"

NewFNP dropped her off at the lab where she, of course, bolted without having her BNP drawn. Oh, Cocoa. Seroquel or no, newFNP just can't give you the help you need to make you well.

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.

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.

Thirty five

NewFNP asked for it.  

She wanted to go part time to save her sanity and now her clinic days are jam packed.  Her days are busier than they ever were before.  It is nuts.  But newFNP is pretty cool with it.  

She's even cool with her depressed patients who can present a true challenge during busy clinic days.  

NewFNP must confess that it makes her a little frustrated and causes her to climb on her soapbox when she sees obvious somatic complaints and notes of 'depressed affect' time and time again in patients' charts yet no one steps up to the plate to frigging ask about it.  

Sure, it may feel as though there is not a lot that one person in a busy health clinic which lacks mental health staffing may do to help that patient.  And sometimes it's absolutely true that providers are just too stressed themselves to take on a depression visit.  But we can't be so stressed that we shelf it to the next visit every time.  That is just shrugging off the job and leaving sad, often ineffective and desperate patients in the same hole.  And it is not true that we can do nothing.  True, newFNP is no counselor, but the act of listening is powerful and making it okay for someone to cry, to disclose a crushingly painful secret, to release some bottled up hurt is therapeutic indeed.

NewFNP has been doing a lot of thinking about what kind of provider she is and what kind she wants to be since she has decreased her clinical hours to part time.  It is so obvious that a smile and handshake is a warm way to start a clinic visit, but newFNP can't honestly say that she was providing that regularly in her darkest hours of full-time employment.  She cringed as she read the NYT health blog and saw her bad behaviors in black and white.  Ouch.  She regained that warmth with her switch to part-time.  

And while she is pretty crappy at orthopedic issues, newFNP is damn good at assessing for depression and she does not want to be the provider who ignores it.  In fact, newFNP has found a new sense of purpose and satisfaction in seeing her depressed patients improve.  The change can be so dramatic - what a joy to see that in someone.  NewFNP has diabetic patients, on the other hand, whose A1Cs have hardly improved since being in her care.  That is not so joyous.

Thirty-five patients today.  And yet, newFNP is happy.  

Weird.

911 on speed dial

EMS presence has been a regular feature are newFNP's clinic recently.  The trend started last week when newFNP had two ambulances at the clinic at the same time - a first for newFNP.

NewFNP's first ambulance-requiring patient was a depressed woman.  She came in complaining of headache, but her affect screamed depression.  As it turned out, she had two suicide attempts requiring hospitalization last year and was suicidal again.  She had a plan (run out into traffic) and means (busy urban area with lots of traffic).  She didn't trust herself to leave clinic and go to a psych appointment the next day.  She wanted inpatient admission.  

She got it.  

NewFNP called her local psych response team at 1:30.  She kept her patient in the room, supervised at all times.  The 'team', which was comprised entirely of one gentleman, arrived at 5:15 PM.  That is when he began his assessment.

NewFNP is a strict believer in not having anyone be alone in the clinic after closing, given that when the lights go down, the sex workers and drug dealers and rival gang member come out.  Adopting a team player attitude, and possibly to get out of his sister-in-law's wedding planning activities, newFNP's clinic manager agreed to stay with her until the psych patient was safely escorted out.  NewFNP and this 24-year old guy were just sitting around when he decided to take a peek outside and find out just where in the hell this ambulance was.  

He returned, clutching his head and telling newFNP that he needed the O2 mask.  Having had a mock code the day before, newFNP briefly thought that he was kidding.  

He was not.  He told newFNP that he had 'blacked out' and couldn't feel his left hand.  He was clutching his left parietal area and complaining of intense pain.  

At this point, newFNP had the suicidal lady and her mental health assessor behind closed doors in room 3, the clinical manager in the lobby and the custodian somewhere in the clinic.  NewFNP quickly assessed the manager, yelled for the custodian and ran to get the emergency equipment and called 911.  

The fire department arrived for the clinic manager at the same time that the first ambulance arrived for the suicidal lady.  It was 6:15.  The second ambulance, expecting to transport the clinic manager to the ED, arrived at 6:25.  NewFNP's clinic manager was hooked up to a portable EKG, normoglycemia confirmed, Romberg negative.  The suicidal lady, much more relaxed, was strapped into her ambulance gurney and departed for her psych evaluation.  

At 6:45, a handsome paramedic asked newFNP, "What time does your clinic close?"  "Five," newFNP replied.

At 6:50, newFNP's clinic manager decided, to newFNP and the paramedics' protests, that he'd prefer not to go to the emergency department after all.  

NewFNP and six firemen/paramedics can lead a horse to water...

Psyched!

NewFNP is no expert in mental illness, but she does know the difference between normal behavior and off-one's-rocker. 

Here are behaviors which newFNP appreciates as falling squarely outside normal.  Capturing pictures of the following subjects on one's cell phone camera: angels, fairies and elves who just hang out in one's bathroom mirror; heaven and hell (same picture); and men walking through clouds of fog on an urban city street.  Also included in this list are movements so exaggerated that newFNP was genuinely concerned about a major musculoskeletal injury requiring a neck brace.  And finally, a crescendo pattern to her speech on each and every subject addressed during the clinic visit - diabetes, soda, moms, returning to clinic the next day, etc.  

This is a patient for whom her support staff tried to room without a chart - a diabetic patient whose sugar was 'HHH' and, according to newFNP's diagnostic skills, is schizophrenic.   When newFNP finally got the chart, she reviewed the previous clinician's note, which noted in her general evaluation that she had an expressive personality.  Expressive?!?  Salvador Dali is expressive, this lady has severe mental illness.

A question which newFNP employs with some frequency is "Have you ever been under the care of a psychiatrist?"  Readers will not be surprised to learn that this woman's answer was 'yes.'  She told newFNP that she took Seroquel for two years after her mom died.    In newFNP's relative inexperience, atypical anti-psychotics are not first-line for prolonged grief.  NewFNP asked this woman if she thought she might need to resume her Seroquel treatment .  Much to her relief, her patient replied that she thought this might be beneficial.  

Psych referral completed!  Now if newFNP could only get her diabetes under control. 

newFNP: truant

NewFNP had a whirlwind of a weekend.  

She worked on Saturday.  She was by herself for several hours as the other provider overslept and the front desk staff continued to allow walk-ins for hours before he arrived, which was pleasant.  She left clinic to catch a flight home for her family's ultra-reform Passover seder (Did the Jews really get kicked out of Egypt 'by management'?  If the gentleman with the yarmulke says so!).  She flew back to her urban metropolis the following day, her flight delayed by an hour which lead to an 11PM arrival.  And then she worked yesterday and saw 30 patients.  

So today, for the first time in almost three years, newFNP called in sick when she is, in fact, not sick at all.  

Friends, it is everything newFNP imagined it could be.  

Early morning bike ride along a scenic route - invigorating!  Trip to Korean day spa for a rub and scrub - not for the faint of heart but also invigorating!  Sitting on modern Crate & Barrel sofa at 3:30 in the afternoon, sipping cold low-fat chocolate milk - glorious!

While totally off topic, newFNP feels compelled to share some thoughts about the Korean day spa.  Not being Korean herself, newFNP's knowledge of Korean culture is limited to her infrequent day spa visits and images of Kim Jong Il on CNN.  

What she can deduce from these limited day-spa-related experiences is that for Korean ladies to have dead skin on any part of their bodies - labia included - is verboten.  NewFNP is at least 10 pound thinner after having her dead skin scrubbed off by a Korean lady wearing a black bra and panties, all while laying naked on a faux Burberry-patterned, plastic-covered slab in scissor-kick and frog-leg positions in a room full of other naked ladies in similar positions!  NewFNP is shiny and pink like a newborn babe and feeling much less self-conscious about her figure flaws.

NewFNP generally feels such guilt about leaving other providers in the lurch, but she knew that there was an extra provider at her site today and she just really, really needed time away from the drab walls and lack of natural light and scabies and uncontrolled DM.

And the best part?  Tomorrow is newFNP's day off!  Fuck, newFNP is getting giddy just thinking about not having to go back until Thursday.  Oh yeah, she is drinking two glasses of wine tonight!

A true mental health day is good for the soul.  And the skin.

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.

Oh, did she go to Hopkins?

NewFNP was enjoying the lull experienced last week thanks to graduations and World Cup. It was all about 20-22 patients per day last week. Well, that lull is over. Thanks a lot, Mexico - way to get eliminated.

The patients are back, and quite a few of them are vexing newFNP. NewFNP must admit that she feels excessive frustration when her patients do not adhere to the regimen she prescribes. Yes, it's the patient's choice whether to go along with the plan or not. However, if the patient chooses not to get with the program, it is newFNP's hope that the patient will not continue to come to the clinic and complain of the same thing over and over again, ad nauseam.

NewFNP's 40-something year old depressed patient with a history of clearly unresolved childhood physical abuse and the full SIGECAPS spectrum reviewed her SSRI/counseling treatment plan with a cousin who advised her to just "work it out" on her own. NewFNP inquired, "Is your cousin a doctor?" Astoundingly, she's not. Nonetheless, blood is thicker than water, even when water wears the white coat. So, OK, Horatio Alger-ess, grab onto those bootstraps and start pulling.

Home sick

No, not 'homesick' as in newFNP is at work and missing her 1-bedroom apartment, but home sick as in see 'formula for success.' More time to devote to old NYT crosswords and The New Yorker.

But anyway, the time spent at home sick can't be all fun and games and cursing one's stabbing abdominal pains. As such, let newFNP tell you three little words that will make any newFNP truly embrace her 'sit-near-the-door' policy.

"I hear voices."

Super. I'm 30 minutes behind schedule and you hear voices. Are you sure you don't just have a cough?

Allow me to set the stage. My mid-40's patient was sitting on the exam table, paper gown and drape in place, and had an affect that quite frankly screamed medicated mental illness. She lacked emotion. She was treated with 2 anti-psychotics and 1 SSRI. Perhaps newFNP should let her psychiatrist know that something in her med cocktail wasn't fitting the bill.

So here newFNP is with the voice-hearing lady. After enquiring as to what the voices said to her and thinking, "please don't let it be 'kill the nice blue-eyed NP,'" I was relieved to hear the relatively benign, "Well, they are babies and they are telling me that I am their mother." OK, doesn't sound emergent.

Then she proceeded, as earnest as could be, "Is that normal?"

Hmmm... normal. Possible responses include:

a) "Normal, shnormal."
b) "I think the attraction to motherhood speaks to a lot of women very strongly."
c) "Who am I to say what normal is?"
d) "No. Shit no, that is not normal. Fuck!"

Now, if community-health-newFNP was an infertility-newFNP, she would lean more towards 'b'. But my community health clinic's scope of practice does not include infertility issues and this lady wasn't speaking about her deep-seeded inner desires for pregnancy. I chose a softer version of 'd' with a splash of 'b' thrown in for flavor.

This patient was not a sexually active lady, but believed wholeheartedly that there was a possibility that she was hearing these voices because she was, in fact, pregnant. Now that is getting into a whole area of religion and mental illness with which newFNP is not comfortable. Urine hcg negative. Let's get you in to your psychiatrist.

All in a day's work.

By the way, the swamp nurse article in this week's issue of The New Yorker made newFNP's job look like no work at all. NewFNP is all manicures and pilates compared to Miss Luwana. Here is a quote from the article:

"The mom I'm working with now is a sixteen-year-old unmedicated, bipolar rape victim and crack-addicted prostitute with a pattern of threatening to kill her social worker, who recently abandoned her baby at her ex-boyfriend's sister's, and who has an attempted murder charge in another situation..."

Now that makes me feel like I am working in a private practice.

Diamonds

In school, we often receive 'pearls' about patient care. NewFNP is more of a diamond type of girl. A little flashier, a little less 1950's housewife. So I'll offer a couple of diamonds from my week.

1 carat: When you have a patient with a low hemoglobin (see 'I hate it when I'm stupid'), re-check the measuremrent in no more than a week. One reading doesn't tell you if they are actively bleeding, but if the result drops then you know that something is rotten in Denmark. Sure, this seems utterly common-sensical, but sometimes when you are new, even the most pedestrian of logical thought processes eludes you. I'm sure you all smarter than me, however....

2 carats: I am screening so frequently for depression and having so many patients disclose that they are depressed. That is not the diamond; just hang on a second. The reason I am screening so much is that I realized that a lot lot lot of my patients had non-specific complaints and an affect that bugged the shit out of me. Now, newFNP understands that that is neither replicable nor sensitive, but the truth smarts at times. So these patients bug, baby, bug. I can't find anything wrong with them, which definitely has the potential to be chalked up to my new-ness. However, I started to think that the headache, back pain, abdominal pain and bone pain, coupled with 10+ annoyingness might be something else. I swear, I pose the question, "Do you think you are depressed?" and watch out! Grab your galoshes and rain caps because the water works start. Then, of course, I feel like a big fucking asshole for my insensitivity and for being annoyed with them in the first place. *I* was the problem, after all, or at least part of the problem. It did, however, reinforce that I need to truly be aware of mental as well as physical health screening *and* that I need to need to trust my instincts.

No more diamonds! Except for Boston FNP, who should check out "The Girl's Attractive" by Diamond Nights.