Ahhhhh......

NewFNP hates to repeat herself, but it is tough to deny that the shit that comes out of a kid's mouth can brighten one's day.

A little background. NewFNP is averaging 30.3 patients per day this week. This is a fact that would give her CEO a big boner but makes newFNP want to stab her eye with a used needle, repeatedly. NewFNP is looking in every corner of every room for the silver lining, but newFNP is fed up. One might even say that newFNP is fucking fed up.

So thank goodness for little miracles, right? And it is unusual in newFNP's life that miracles take the form of fat 9-year olds, but it seems as though miracles do indeed work mysteriously.

This chunky guy was midway through his physical when newFNP instructed him to lie down for the old abdominal exam. Reclined comfortably, he closed his eyes, stretched and sighed, "Ahhhhh, I knew this day would finally come......" He was so serene and sincere, as though he had stepped into the day spa. Or did this patient think he had stubled upon the Best Little Whorehouse in Anonymous Urban Center?

As his mom, older sister and newFNP were chuckling, this Hugh Hefner protoge continued. "I knew that one day I would be here and be examined thoroughly." Now, newFNP knows that this little kid did not intend for his comment to sound creepy or weird - let alone pornographic - and he probably didn't even intend for it to be humorous. But he indeed did receive a thorough exam and is off to urology as a result. Did his big genital fat pad eat his testes or were they never descended to begin with? That is for Dr. Penis to decide.

There was a distinct lack of awesome little kid comments today, however. NewFNP could go for one tomorrow. NewFNP could also go for a day with 20 patients, a new Miu Miu handbag and some raspberry-colored Marc Jacob's patent leather wedges. Alas, newFNP thinks that the wedges are a more achievable desire than is a light clinic day.

Office staff rant

A tough thing about being newFNP (or supervising MD or co-worker NP) is that there are no other employees in the clinic as responsible or as knowledgable as you. In some ways, that's fine. In other ways, it makes newFNP want to yell at people and throw her pens at them.

NewFNP's biggest pet peeve in not having labels in the chart.

NewFNP is the third stop in the clinical flow. First stop - front desk. Second stop - MA/vital signs. Third stop - newFNP.

As evidenced by the above written flow chart, here are at least two people ahead of newFNP who can open the chart and see that there are, in fact, no labels. Ultimately, the front desk needs to take a split fucking second and look in the chart. Are there labels? No? Print them out!

Ten minutes later, when the MA writes down the chief complaint and sees that there is no label with which to identify the patient on a new progress notes page, she then has the opportunity to ask the front desk to print out some labels.

Now, newFNP is not sure how often the aforementioned scenario occurs, but she is quite sure that it did not happen three times today, a day in which newFNP was responsible for the care of thirty-four patients. On such a day, newFNP finds it difficult to be polite when wasting precious minutes of her time to go do someone else's job. It is not as though newFNP has neglected to mention this ever-present need for labels to all clinical staff during weekly staff meetings. To the contrary, time and time again, newFNP has pleaded with her co-workers to throw her a fucking label bone. Alas, no.

Ranking second on newFNP's list of pet peeves is incomplete or an absolute lack of lab results in the chart when a patient's clearly stated CC is "lab results." Should it ever happen? No. Should it happen daily? Hell no. Does it? Shit, yes it does. This causes newFNP to hunt down her MA and request the results. Sure, newFNP could find them faster herself, but fuck that just on principle.

There are many other things our MA's miss. Some of it a simply a lack of knowledge and newFNP is not going to fault them for having next to no education. However, newFNP attributes a decent amount of MA oversights to sheer laziness. And newFNP is pissy about that. NewFNP has struggled all year with the fact that she is working like she is on the chain gang all day long while she sees other employees looking on MySpace and taking 10 minutes to figure out from which fucking fast food restaurant everyone wants to order lunch.

Being at the top of the intellectual food chain in one's community health clinic is at times a welcome responsibility and a frustrating burden. NewFNP sincerely believes that it would not take much effort on the part of other staff to ease the workload of the clinicians. Sure, we'll see the 25-30 patients per day. Just make it a frigging smidge easier on us.

Geez!

Pediatricity

NewFNP feels that she is not alone in declaring that, for FNP students, pediatrics can be daunting. Kids have high fevers, they have weird rashes that may be viral or may be frigging measles. Who knows? What new NP has ever seen measles? What parent feels confident in the diagnosis of 'viral exanthem'?

Nonetheless, pediatric visits have turned into the highlights of newFNP's day. Why, just this week, newFNP had a five year old boy laugh and scream, "You're touching my penis!" during a regular old testical exam during a well-child check. You just don't get that kind of enthusiasm during the adult exam. A four year old boy this week told newFNP several times, "You're funny." And, damn it all, that kid is right. NewFNP was having a grand old time chatting up this four year old about school, his cousin, crying, Batman - a little sample of all things important.

For all the students, newFNP thought she would share some secrets to help overcome the fear of pediatrics for you and your patient.

1) This lesson is courtesy of Sunshine, a co-ed with whom newFNP studied. New FNP uses it without fail. Kids hate the ear exam, but looking for Dora or SpongeBob in a kid's ear will greatly facilitate the process. Sometimes newFNP tells the kid that she saw Dora running to the other ear and they graciously turn and offer the ear for examination. This tool is not limited to the ears, no sir. It works on the mouth too!

2) Making an amazed face upon cardiac auscultation is a wonderful tool to get kids interested in what's up. Of course, older kids can listen to their own hearts, but the young kids like to see that you think their body is working well.

3) Knowing when you don't have to do a full exam is important. Not every well child check needs to be a head-to-toe. If kids are scared and crying, newFNP lays off, especially if they are a regular patient. NewFNP explains her lame exam to the parent, letting them know that being scared is normal and that newFNP will provide a more thorough exam when the child is not screaming and kiding under the chair.

4) Tell parents to bring the kid back the next day if you're concerned. In newFNP's experience, parents don't appear too put out when it comes to their kids' health. You can also try obvious things like oral rehydration and fever management in the office. Duh.

"You're touching my penis!" Ah, good times.

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.

Knocked up

As a part of newFNP's continuing growth, development and work stress, she has taken on the role of prenatal care provider.

Here is newFNP's ideal first prenatal patient: 25 years old, normal weight, 8-10 weeks pregnant, non-smoker, no drugs or alcohol, taking prenatal vitamins, stable home life. She can have a cup of coffee per day because, come on, newFNP isn't a fascist.

Here is newFNP's actual first prenatal patient: 22 years old, G3P2 with a 7-month old, living in a shelter due to IPV, quit her 2 PPD smoking habit "2 weeks ago," in the 19th week of her pregnancy seeing newFNP for the second prenatal visit of this pregnancy, no prenatal vitamins, with both children in foster care, overweight and missing a front tooth. NewFNP knows that the front tooth isn't relevant, but it does paint a certain picture. Did newFNP mention that this patient was a walk-in? Of course she was! Only the non-complicated patients seem to make appointments in newFNP's clinic.

Trial by fire, this prenatal care bit.

Look at all of the opportunities newFNP has to provide education, support and care.

That is newFNP's new mantra. The old was one "fuck this" and that mantra just doesn't always work.

Celebrating one year of newFNP

Three hundred and sixty-five days ago today, newFNP had just completed her first day as newFNP.

NewFNP saw five patients that day - today it was thirty.

NewFNP is certain of one thing - being nice to patients makes all the difference in the patient experience of their care. NewFNP had a patient last week with cerebellar ataxia. What is cerebellar ataxia, you might ask. That is precisely the question newFNP was asking herself as she sat staring at her patient. No matter, because newFNP was nice and took time to talk to this woman. Midway through her visit, she told newFNP, "I want you to be my doctor." Well, sister, newFNP can't be your doctor but she can be your FNP even if the only thing she knows about cerebellar ataxia is that she needs to get your ass to neurology.

NewFNP also has to remind herself that many people in her practice are, quite frankly, health illiterate. Many people do not know how to care for themselves; they don't know the difference between what is healthful and what is dangerous. For newFNP, that is sometimes hard to fathom. Before newFNP was newFNP, she knew that Gatorade was not a health drink. She didn't learn that in NP school or in MPH school - she just knew from sometime long ago.

This lack of basic health knowledge is frustrating to newFNP at times, such as today when she had an urgent walk-in for, no joke, a bruise. A run of the mill purple bruise. But as newFNP felt herself thinking, "What in the motherfucking fuck is this person doing here," she backed off that ledge and remembered that this person was in clinic to get newFNP's professional and educated opinion about her bruise.

Ah, the wisdom we amass.

Although newFNP has yet to submit her request for a salary increase, she did receive a brand new chair at the end of the day today. For the past year, newFNP has had this ghetto-ass hoopty chair. No more - newFNP is now ergonomically correct and does it ever feel good. Now if she could only get a computer.

***************************

Thanks for sharing this year, newFNP readers.

Scoot down

Quite frankly, newFNP does not understand how it is that women who have had many children, who have had prior pelvic exams, and who are in their 30's & 40's do not understand that they need to scoot that shit down in order for newFNP to do a pap. NewFNP feels a bit akin to Hannibal Lector as she repeats, "Closer. Closer, please. Closer." Imagine, if you will, a woman on the exam table, feet in the stirrups, legs fully-extended. What do they expect newFNP to do? Shimmy up on the table with them in order to get a peek at their cervices? And why is it when newFNP instructs them to move closer to the edge that they inch their way down the table? Is there an epidemic of women falling from the exam table - ass first, feet a-tangled in stirrups - that has these women stricken with fear about scooting? Ay ay ay.

You're fine, now go away

Frankly, having no insurance sucks.

NewFNP had a patient whom she began to treat for anemia last week when she entered our clinic with a heavy period and a hemoglobin of 7.2. For those not in the know, that qualifies as 'fucking anemic' as opposed to 'holy shit, is this patient ever anemic.' NewFNP's approach was three-fold:

1) iron supplementation (duh) and repeat hemoglobin in 48 hours
2) oral contraception (no provera available in the clinic)
3) CBC

Upon said patient's return, her hemoglobin had increased to 7.4, not an amount for which anyone will win any prizes but enough to calm any fears of imminent bleeding out. This is no faily tale, however as this lady's OCP was causing vomiting and a lot of it. NewFNP operates from a philosophy of avoiding insult to injury and, therefore, changed up homegirl's pills.

Alas, while the patient tolerated her new pills well, her menses was one tough customer and didn't feel the need to leave her the hell alone. She went to the ED and received 2 units of blood. Although newFNP did not see her in follow-up, she did see that her hemoglobin was a nice 11.8 the next week. Her period, however, was tenacious! It was not to be stopped by hormonal contraception alone. She was referred to an OB/GYN and received essentially no care.

She returned to newFNP's clinic the next day, clutching her head and crying in pain. She had been seen in the ED the night before, received no imaging and was discharged with a diagnosis of migraine. In the clinic, her right eye was deviating from its normal gaze. She was the most distressed patient newFNP has seen, excluding of course first rectal exams and male GU accidental erections. NewFNP called 911 and the friendly firemen took her to the hospital.

A quick phone call to the patient's home the next day revealed that she was, yet again, discharged with no imaging and told that she needed to see a neurologist. Yeah, no shit ass-crack. That's why newFNP sent her to the fucking hospital in the first place. How the fuck can we tell if the reason she has such heavy periods isn't from some underlying bleeding disorder that is causing her to also bleed in her brain if we don't do imaging?

When a 17-year old with anxiety comes into newFNP's clinic complaining of chest pain, she is likely to get the full cardiac work-up (read: an EKG and auscultation in all essential spots instead of just one or two). When a tyke with a sore throat comes in, newFNP checks him out as though he could have something aside from the 85% likelihood diagnosis of viral pharyngitis. NewFNP does not send every case to the ED. Apparently, that's a good thing given the crappy care they receive.

NewFNP knows that the EDs are overburdened with patients as well, but seriously, what the fuck?

Hold the mayo

There are days during which patients just break newFNP's heart.

Imagine having gone through a fetal loss, an ectopic with subsequent tubal scarring and years of infertility before finally meeting a reproductive endocrinologist who will work with you when you're uninsured. Imagine being evaluated for Clomid and preparing to start using it. Then imagine finding a breast lump. Then having a fine needle biopsy with a "bad" result. And then imagine the waiting between those results and your impending excisional biopsy, when you have nothing to do but think of how you're not pregnant and how maybe you have breast cancer just like the beautiful woman sitting next to you in the breast clinic when you had your needle biopsy.

And on top of all that crap you get a cold and end up in newFNP's care. Son of a bitch, right? That's just what you need!

NewFNP breaks the touch barrier a lot. She believes that a handshake or a simple pat on the back or the arm goes a long way in welcoming patients. NewFNP took this patient into her arms today as she sobbed.

So, yes, there are days when patients just break newFNP's heart. Of course, there are also days during which patients just bust newFNP's chops as well.

Today was a combo platter.

Fine art

NewFNP has no personal opposition to tattoos. In fact, she must admit to having had a certain attraction to some tattooed gentlemen now and again. In fact, it has been rare - if ever - that newFNP has felt morally and personally offended by a tattoo. NewFNP supposes that there is a first time for everything afterall.

While conducting a physical exam, newFNP noticed that her patient had half of a buxom naked lady peeking out from under his mid-calf-high gym socks. Not only was this lady stacked, she was also sitting with her legs widely spread, knees bent. Although her nether regions were covered by the gym sock, newFNP had a guess as to what was hidden beneath. Well, in case newFNP was wrong in her assumption, when she walked around to the patient's side, she got a glimpse of something she had never imagined anyone - save for disgusting perverts - would want eternally portrayed on their external calf.

NewFNP must confess that the artist was clearly a student of the female external genital anatomy. Professional or lay, this tattoo artist knew his stuff. NewFNP can't be certain, but she thinks that she saw a Skene's gland. In any case, is it necessary or even desirable to have a 7-inch tall tattoo of a naked and anatomically accurate lady in the doggy-style position, fingering herself , and glancing longingly over her shoulder? NewFNP thinks decidedly not.

NewFNP has thought about this a lot - not the tattoo, per se, but her reaction to it. A) NewFNP felt offended. Period. B) NewFNP did not want to continue to provide much care to this individual who clearly has low regard for women. C) NewFNP felt sorry for this person's daughter.

Maybe newFNP should have suggested tattooing underpants on the lady. Or maybe she could have just said, "Oh - I see you have a fucking repulsive tattoo. Do you have a difficult time getting laid?" But she didn't. She just did a quick exam and moved on to the next 50 million patients that day.

Gross.

But it's 4:53 PM

Here is the patient who should be the 4:45 walk-in: tinea, 1 lesion. That's it. You have ringworm, welcome. Please come in and accept my anti-fungal treatment. And then leave so that newFNP can too leave in order to make it to her overcrowded, under-air-conditioned gym prior to all of the elliptical machines being hogged.

Here is the patient who should not be the walk-in at the aforementioned time: the never before seen in our clinic 63-year old lady with the visibly pulsating carotid. It wasn't small, nor was it subtle. It was reminiscent of the boils on the truck driver's neck in 'Harold & Kumar Go To White Castle,' a must-see movie as far as newFNP is concerned.

In considering this patient, newFNP has but two words: time bomb.

Carotid bruit? No. Hugely wide carotid with a loud - and newFNP does mean loud as all getout - pulse. Is it an aneurysm? Possibly. Whatever it is, it needs more in-depth evaluation than newFNP's little community health clinic can provide. And did I mention that her BP was 144/40? Well, it was. NewFNP likes to call that a "wide" pulse pressure.

So, to sum up: wide pulsating carotid + wide pulse pressure = good-bye pulsing neck lady. Enjoy the ED. NewFNP sincerely hopes that this trip will save her patient's life.

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.

You think you had a bad week?

OK, listen. There are many difficult situations which newFNP must control in the course of a work week. These include, but are not limited to, the following quotes from patients and/or clinical experiences from last week:

• 'I stopped taking my Benadryl because it makes my eyes hurt.'
• 'My cholesterol medicine makes my throat hurt.'
• 'My hernia [umbilical] is hurting and I didn't go to my ultrasound appointment, nor did I call to cancel or change the date.' This is a paraphrase. This same patient also told me that she felt "little balls" on her abdomen. Yeah, sister, that is called cellulite. Tummy cellulite. Now goodbye.
• 'All I eat are fruits and vegetables.' Hmmm.... 276 pounds and a glucose of 350, all from those dastardly fruits and vegetables? Perhaps newFNP is approaching diabetes care all wrong.
• Let's see, what else: fat kid, fat kid, fat kid, kid with possible ocular tumor, fat kid with hypertension, primagravida with a fetal ultrasound too devastating to describe, fat kid, hugely fat adult.... you get the picture.

But do you know what made last week a fucking nightmare? I'll tell you.

NewFNP has lost her palm pilot. The son of a bitch is gone, along with ePocrates, Kid-O-Meter, BMI Calculator, 10 year risk assessments, my hairdresser's phone number, my facialist's phone number and a plethora of other useful information. NewFNP has a new PDA on the way but misses her piece of crap Clie.

Sony Clie, wherever you are, newFNP loves you.

It's not you, it's me....

NewFNP has had some tough conversations in her day, ranging from "Well, I actually am not a real fan of purple angora mock turtlenecks but thanks for the thought" to "You have chlamydia" to "I really feel like this is not working out with us." Now she has had the "You have cancer" talk.

As with any break-up conversation newFNP has had, the build-up was worse than the event. NewFNP was surprised, quite frankly, at how unaffected the patient was upon hearing the news of her cervical cancer. Perhaps she didn't understand, perhaps she was shocked, perhaps just stoic. Her daughter, on the other hand, appeared to grasp the magnitude of the diagnosis and perhaps her mother's mortality.

In speaking with the woman and her daughter, newFNP asked again when the patient's last pap had been. Her daughter asked, "Two years ago, right?" Her mom replied that she had never had a pap and that the exam two years ago was a mammogram. This is a multiparrous woman - no pap ever. NewFNP is struck by the frequency of that experience in her patient population. She also is reminded of how important it can be to ask the same questions over and again, especially if your communication is compromised by language issues.

As newFNP has had time to reflect upon the initial appointment, she is struck again at how she initially doubted her eyes and her knowledge and how, upon receiving the result, she began to appreciate her abilities. As newFNP reflects upon the care uninsured people receive, she is struck by how flat out fucked they can be. NewFNP has awesome insurance at a very hoity-toity facility. She has a palpably and audibly crunchy knee that needs evaluation. She received her appointment the same day as her primary care physician generated the referral. NewFNP's patient has a big ole tumor in her va-jay-jay and our referral coordinator couldn't secure a colpo/biopsy appointment for her. She had to walk into a specified clinic, lab result in hand, and get medical attention.

Her biopsy was last week, as was her CT scan. NewFNP is awaiting the results, fearful of what they will bring.

Although it didn't feel good to tell this woman that she has cancer, it felt right. It felt respectful to deliver difficult news straightforwardly and compassionately, to answer questions and to be a support.

Now let's get those HPV vaccines rolled out and prevent all these abnormal paps, biopsies, cancers and deaths.

A plea

Ladies, please - hear me out.

Now, newFNP knows that all members of the fairer sex will at some point be afflicted with nipple hair, or more specifically, peri-areolar hair. NewFNP is not of hirsute stock, yet even she has had to endure this hardship. But what makes this tragedy something one can easily overcome is a little something called tweezers, a not-so-new technology. NewFNP opts for Tweezerman, but she is sure that even Revlon makes a pair that would be suitable for boob tweezing. Especially when your nipple hair is coarse like a man's and two inches long like a certain recent patient in clinic. So, please, cut newFNP some breast exam slack and tweeze.

Disclaimer: newFNP considers herself 100% feminist and does feel some guilt regarding both this post and her aversion to whatever makes her female patients happy as far as breasts go. NewFNP will send a check off to NOW right away.

Right after she sharpens the edge of her tweezers.

Oh, to be wrong!

Normally, newFNP enjoys being correct. NewFNP likes good grades and completed NY Times crossword puzzles (only the Sunday magazine crossword, not the NYT crossword). At this relatively early stage of her career, newFNP also enjoys correct diagnoses. When she presumptively treats a strep throat while awaiting culture results, she feels selfishly relieved when the cultures are positive.

NewFNP, however, is not so pleased with her correct presumptive diagnosis in her sweet 68-year old patient. This woman's chief complaint was urinary incontinence, but she also noted a very foul vaginal discharge. Oh, and some vaginal bleeding. Not all the time, but vaginal bleeding nonetheless. The words "post-menopausal vaginal bleeding is cancer until proven otherwise" rang in newFNP's head as she was taking the history.

Other pertinent info:

• no sexual activity for many years
• last pap 2004 - patient assumes it was normal
• vaginal discharge progressively worsening over 6 months
• vaginal bleeding times 4 months - intermittent

It's newFNP's understanding that there are some vaginal infections that present themselves even before the patient is in the lithotomy position thanks to the ol' olfactory system. NewFNP had yet to experience such an infection until meeting this patient.

Although it feels insensitive to say it, newFNP had to choke down her gag reflex during the exam. The odor was reminiscent of abscess contents. The discharge was green and, man alive, was it ever copious! It was literally running out of the speculum as fast as newFNP could swab it.

Now, newFNP frequently wonders if cervical lesions will be visible to the naked eye. Ectropion, sure. But what about those purple lesions? Are they moles? Should I know this? Whenever newFNP sees something she is unclear on, she makes sure to get a nice sample of it for the pap. Well, what this lady had going on was so visible that newFNP had to look at it many times over to actually believe what she was seeing.

If memory serves correctly, the chart note read something like: Gray round lesion, approx 1.5 cm, rough surface, adjacent to cervix at 3:00. Friable.

The referral note states: Rule out gyn cancer. Pap pending.

The pap isn't pending. It was faxed to newFNP today. Squamous cell carcinoma. No BV, no trich, no gardnerella. No GC/CT. All of that discharge must have been necrotic tissue sloughing off.

In the next few days, newFNP will be, for the first time, telling a patient that she has cancer. In Spanish. In fucking Spanish.

It is horrible to be right sometimes. Yet, it does reinforce the adage that seeing enough normals will help you to recognize the abnormals. That, however, isn't enough consolation for newFNP right now.

What a feeling!

Apparently, newFNP's HR department has nothing better to do than to come up with new policies regarding professional attire. There were some expected no-no's, of course, such as a prohibition against shorts and half-shirts. Sorry, Beyonce, no job for you at newFNP's clinic!

There were, however, some unusual frowned upon fashion pronouncements. For instance, it is "inappropriate" to wear khakis or chinos. I'm sorry, but where is it appropriate to wear khakis if not to work? Also not making the cut were clogs, of all things. Sorry Dansko. You'll have to appeal to the Dutch because the community health clinic says you are inappropriate.

The most unusual fasion item to make the "no" list were... wait for it..... stirrup pants! Please, someone tell me, what is newFNP going to wear with her leg warmers, headband and off-the-shoulder sweatshirt? What's next? Outlawing Forenza oversized v-neck sweaters and Members Only jackets?

Char-que?

There are times throughout the day during which newFNP sees her patient and immediately senses a "what the fuck" coming on. What newFNP would like to do is gingerly tiptoe backwards out of the exam room, hoping that the patient never noticed that she was there.

Given the state of affairs of one patient today, newFNP could have probably succeeded in the aforementioned exit strategy.

Before continuing, can newFNP just make one more plea to prevent frigging Type 2 diabetes? Yes, yes, we can't save them all, but newFNP is sure as shit saving herself. And if a gaggle of patients want to set sail in the health boat with newFNP, they can hop on board. Ahoy!

Here is why "Develop Type 2 DM" is not on newFNP's to-do list.

A) Renal failure.
B) Proliferative retinopathy/blindness.
C) Peripheral neuropathy/amputation.

And if that weren't enough, newFNP has a new reason to add to her list: Charcot's Foot - a complication of neuropathy that leads to fractures of the bones without having experienced major trauma. Because of the neuropathy, the fracture isn't felt by the patient who continues to walk on the affected foot. This, in turn, leads to severe deformities, sometimes intractable ulceration and the potential for amputation.

If you haven't seen Charcot's Foot before, conjure images of Kathy Bates' character hobbling James Caan in "Misery." That is what Charcot's looks like. It's swollen, warmer than surrounding skin and looks like someone took a sledgehammer to it.

And if that wasn't incentive enough, just think of this: Charcot's Feet cannot wear cute shoes.

Parenting 101

A little about me. NewFNP is not a parent. However, newFNP knows crappy parenting when she is beaten over the head with it.

Take for instance the mother and daughter pregnancy test walk-ins this week. Mom in her late 30's, daughter in her late teens. Mom's test negative, daughter's test positive. Mom relieved yet concerned about having had two menstrual periods the previous month. Daughter devastated, crying, fallen, crushed.

Mom wrapped her arm around her daugher's shoulders and told newFNP that her daugher had been raped in February. NewFNP inquired as to post-sexual assault care. She had none. No health care, no police report. No menstrual period for two months. No knowledge of whether she had been infected with an STI. No counseling.

Mom repeated over and over to the daughter, "It's OK, it's OK." OK? Fourteen weeks pregnant as a result of a rape is OK? No, not OK. Pretty fucking far from OK.

After a 20-second series of "it's OKs," mom turned her attention back toward herself and inquired as to her irregular periods. NewFNP said something polite but dismissive in order to re-direct the conversation to the daughter. Mom played along, but would not be deterred from receiving the answer to her relatively pedestrian query. NewFNP encouraged her to follow-up with an appointment. What newFNP wanted to tell her was to drop it and to focus her attention on the needs of her re-traumatized daughter.

Is newFNP out of her tree or is there a time during which you let your needs fall aside in order to deal with a crisis? Isn't that part of being a parent? That's part of the reason why newFNP is sans child - still selfish, this newFNP! Still putting her needs first.

Speaking of, J. Crew has some cute frigging spring flats. Perfect with smart trousers for clinic-wear!

Wet to dry

It's not until one washes one's hand three trillion times per day that one truly appreciates the drying effects of water. It's Saharian in its drying capacity. However, one can certainly understand how a patient who is told that she needs a wet dressing in order to dry a seeping wound might raise an 80-year old eyebrow and toddle off to the pharmacy to buy some more minty-cream.

NewFNP was happy to take a look at her patient's wound yesterday. In fact, when newFNP was in her whirlwind med-surg rotation, she was somewhat of a wound guru. Well, folks, those days are long-fucking-gone. As newFNP unwrapped the homemade bandage and caught a whiff of the minty salve, she began to realize the extent to which one year of untreated wound festering can wreak havoc upon delicate ankle skin. What began as a "vein" that she scratched with her shoe turned into a large - let's say 5 inches in diameter - ulcer covered with thickened yellow necrotic tissue.

She has been using all matters of salves and creams for the past year, all leaving her unfulfilled and with a growing lesion. The scent of the cream she was rocking in clinic yesterday was reminiscent of kindergarten paste and she had applied it just as thickly as would a 5-year old. She told me, with utter contempt, that one doctor told her that she should just cover it with water and that it would heal. The tone in which she conveyed this story implied, "As if."

When newFNP prescribed the exact same treatment, she wrote the kindly old lady a prescription for sterile water and told her that she needed to use this "special water" to heal her wound over the course of the next year.

Special fairy water - that's what newFNP will say next time.

Body count

Hours worked: 8
Number of patient visits: 27
Number of complete physicals: 6
Number of IUD insertions newFNP did for the first-ever time: 1
Number of third-graders weighing in at greater than 100 pounds: 2

Number of weeks of vacation newFNP currently receives through her clinic: 2
Number of sick/personal days: 4 - total, not each.

Sure, newFNP understands that she earns approximately 10K under market because she works in community health. Sure, she is savvy enough to reason why she is forced to see so many patients day in and day out.

But what newFNP does not understand is why her clinic's management does not seem to address the concept of "burn out" and spend some time considering what it might do to prevent it from happening to its employees. All newFNP wants is 4 weeks of vacation per year. Yes, it's a lot. No, it is not at all unreasonable.

NewFNP suggested this change to the doc with whom she works, who in turn suggested it to senior management. NewFNP is anxiously awaiting their response. Her passport is current and aching for some new stamps.

It's nippy out

Ah, fashion. NewFNP loves fashion. NewFNP loves shopping. Just to descend into the warm embrace of the Prada SoHo, to flirt with the sassy Sigerson flats, to luxuriate in the sensation of a Theory cashmere sweater against one's cheek - even at the outlets! NewFNP loves it all.

There are, however, some fashion trends newFNP just can't endorse. These include MC Hammer pants. Can't touch this? Yeah, no shit - who would want to with those baggy ass yellow trousers? Also on the list are jelly shoes, even Marc Jacobs jellies. A current fashion forward look which newFNP finds revolting are the gladiator sandals. Go away with your leather ties up your legs. It's ugly and slutty looking.

A look that has likely not graced the pages of Vogue or Marie Claire in some time might be the half-shirt. As fashion forward newFNP readers know, longer tees are in. Bare midriff - out.

Apparently, our 275-pound walk-in yesterday morning didn't get the memo. She also must have missed the memo that it is important for breast health to wear a bra. She clearly missed the memo stating that one's ample bosom belongs inside one's half shirt as opposed to hanging out of the bottom, nipple pointing directly to the floor.

Is newFNP wrong, or is it very unusual for a woman to bear her nipple in public? Granted, newFNP lives in a rather progressive city where the climate is mild and where boobs are an important accessory. Nonetheless, it is newFNP's opinion that one must be utterly divorced from reality to A) find it acceptable to share one's lady-goods with all of the clinical staff and patients or B) not realize that one's nipple is actually out of one's shirt! I mean, come on, isn't it even a little cold? Isn't there a breeze with which to contend?

Bottom line: newFNP is no conservative, but she votes to keep the nipples in the shirts when in public.

I had this pain....

When newFNP has a pain that self-resolves, she is thankful and happily moves on with her life. That is not the case, however, for many of newFNP's patients. I cannot begin to tell you the frequency with which I hear of bygone aches and pains, now entirely resolved.

So you say that your back hurt 3 months ago? Interesting.

What's that? You had a headache last year, just once and then it went away? Well, aren't you a medical miracle.

Pardon me? What caused that pain you experienced last July? NewFNP must confess, she'd be hard pressed to say.

Lest anyone think that newFNP is an asshole, she does in fact inquire as to whether there are any other health concerns that might have brought the patient to the clinic. Most frequently, the answer is no. Sometimes, however, there is another chief complaint.

One such example is my mid-30's male patient who segued from resolved pain to constipation. Ah, poop. Now there is something you can really assess and sink your teeth into during the history-taking!

For instance, when was your last BM? Today.

I see. And how often do you have a BM? Every day. Twice a day.

This is the point during which newFNP questions her Spanish skills. Twice a day? Constipation? Something is not adding up!

OK, well, twice a day falls well into the range of normal...

At this point, newFNP's patient won the Brown Star Award when he disclosed his normal bowel pattern of three movements per day. Maybe the day after Thanksgiving, but every single day?!?

As newFNP sees it, Mr. Poopie has just saved himself an estimated roll or two of TP per month, not to mention an estimated 30-45 minutes per week away from the throne.

Perhaps he could devote that saved time into an extra workout!

Exactly

Every day, am I right? Thirty minutes? Yeah, me too.





Sorry - font so small and newFNP so unable to fix it. Caption reads: Be honest - how much are you exercising?

Strapped for cash

No, newFNP is not here to complain about salary, although it is too little to support major urban area rent, plus shopping - and not even at Barney's, plus student loans. No, at this point, it seems as though newFNP's clinic has bigger fish to fry.

You see, as in many other metropolitan areas, newFNP's metropolitan area has a significant population of uninsured people. NewFNP's clinic offers 100% free services to these people, including the dispensing of some medicines. No, we do not offer Botox, but we will do our part to keep a patient's A1C at a reasonable level. As such, newFNP's community health clinic in positively out of money for uninsured patients. Imagine newFNP pulling her empty pockets out of her flattering Theory trousers, shrugging all the while, and you'll get the idea. The well is dry.

So, what next? How does newFNP provide an acceptable level of care to these patients if she can neither order labs nor dispense meds? NewFNP is already sensitive to the financial strains of community health practice. Should newFNP provide more thorough care to her insured patients than she does to her uninsured patients? The thought is unsavory at best. And unethical, according to newFNP's ethics.

Our finance department has placed a stop on all of our orders as a result of these dire straits. How much has this administration spent on Iraq, Afghanistan and the bullshit Social Security overhaul? How much was spent on a certain state's special election in 2005? How much do the Boston Celtics earn collectively? NewFNP will tell you what - it sure as fuck wouldn't take billions to keep our patients healthy.

So far, newFNP's clinic remains relatively well stocked. However, if we run out of gloves, newFNP is placing a moratorium on all rectal exams. Hey, you've gotta draw the line somewhere.

You can't keep a good newFNP down

Since newFNP last exposed herself to a patient's aromatic purulent discharge in a not-altogether successful attempt, newFNP has incised and drained not one, but two further patient lesions.

Lesion one: lady business abscess. OK, not exactly lady business but suprapubic in locale and wholly a result of picking at one's ingrown hair. Hands. Off. Ingrowns. I restate my case initially argued in "Picky Evolution."

Lesion two: epidermoid cyst. NewFNP has been waiting for this since she first became acquainted with one during her independent study in derm.

NewFNP is floating in her derm dreamworld. Oh, how newFNP loves derm. Bring on the Retin-A, kiss that acne and those wrinkles good-bye. NewFNP would love to scrapy-scrape your big fat plantar's wart, just as she would love to inject your inflamed acne lesion with kenalog. NewFNP loves to draw pics of derm lesions. NewFNP simply loves derm. It's a pure, unadulterated love.

OK, back from dreamworld. So, an epidermoid cyst. Not pretty. It forces one to utilize culinary analogies when describing cyst contents: cheesy. Soft cheese. Soft white cheese. Rondele, anyone? The I&D is exactly the same, except that you want to get the sac which contains the contents out in order to prevent recurrence and numbing the patient is so much more difficult. The contents of the cyst are firmer and therefore require a larger bored syringe in order to introduce the lidocaine. Ouch, big fat needle.

What can ruin a perfect I&D is another provider's student attempting to horn in on the I&D action. And by horning in, newFNP means asking not once, not twice, but five times to either perform or observe the I&D. At each query, newFNP replied 'no,' each response becoming progressively more firm and annoyed, the last of which being, "You can stare at me all you want; the answer is no." Is the student six years old? No, no she isn't. Yet newFNP found herself speaking to her as though she were. There is a reason that newFNP does not have a student: because newFNP needs the experience herself. NewFNP still is gaining comfort in her role as pus-expressor.

Note to all students: when your preceptor says 'no,' there is a reason. Don't push it. Should newFNP even have to tell anyone that? NewFNP is certain that her readership is already savvy enough to realize the non-kosher maneuver by our student.

In the end, not even pushy student could spoil the supremely successful I&D. NewFNP was even able to disrupt and express the sac. You can imagine my happiness - bordering on beatitude.

Out of the mouths of babes

NewFNP has fallen in love with the well child visit. Yes, it's true that sometimes the 13-year old well child weighs more than newFNP. Thankfully, those visits are rare enough. But for the most part, well child visits afford newFNP a break from diabetes and BMIs of 45. NewFNP likes all kinds of well child visits now, but has always held a soft spot for teenagers. Especially ones that ask funny questions.

So, all in all, an average 14-year old male well exam. Thin, plays field hockey (quite unusual in my inner city area), respectful, has all parts intact and has no inguinal hernia. Testicular torsion education - done. Safer sex/abstinence education - done. Repeated denials of current or prior sexual activity - accepted by newFNP.

As always, when about to exit the room, newFNP asked, "Do you have any questions?"

"Yeah, I have a question," he replied. "Is it bad to masturbate?"

The way he asked was so sincere. I set the chart on the counter, faced him squarely and said, "No, it's not bad. Everybody does it. Just don't get caught."

He was visibly relieved. Whacky kids!

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!

And the hits just keep on comin'

NewFNP has been on hiatus, largely although not entirely due to a lack of fun/interesting stories to share. Nonetheless, as newFNP indugles in a some moments of reflection here and there, she finds that there are some stories worth sharing.

In the on-going series of firsts, allow newFNP to share some of the new experiences she has had in the past two weeks:

-first patient passing out, becoming diaphoretic and having a BP of 68/42 and a HR of 40 during venipuncture.

-first patient with 8+ hours of uncontrolled epistaxis coupled with first experience of being unable to find 1:1000 epi and served with a side of being the only provider in the clinic.

-first realization that my 19-year old patient is engaged to and not the daughter of my 58-year old patient. Permit me an aside, s'il vous plait. Upon further questioning, this young woman disclosed that she and her partner had begun "dating" when she was an assumingly worldly 13-years old. Their son is three. What was her life like that a then 52-year old man was attractive to her? Where were her parents? Why did the man troll down that path of pedophilia? And why is the gentleman I know today, the same man who was screwing a child, so incredibly likeable?

-first suspected child abuse reporting call, only it wasn't suspected. Note: don't forget to ask what the child is hit with, ie. a belt, a hand, a shitty start to life.

-first time of blinking back tears due to feeling utterly overwhelmed, suprisingly not on the same day as the child abuse report.

-first time looking in an ear and seeing something resembling the aftermath of a roadside bomb. Shades of red and gray, jagged edges to a clearly blown TM. Tumor v. traumatic rupture of TM? Let's have the ED decide.

Oh, life. Is it too soon to ask for a raise?

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.

The formula for success

Gentle reader, it is vomiting and diarrhea a-go-go here in newFNP land. We have seen countless children over the past few days with all manners of fluid evacuation. Patients have it. Staff members have it. Children of staff have it. Will anyone escape? My facialist is always telling me that I need a colonic in order to have perfect skin. Maybe she's got it all wrong. Maybe I just need some acute gastroenteritis to flush out the toxins!

Alas, the toxin-flushing argument is likely not going to be a winner with a worried parent. So what do you tell the patient's worried mom? Sure, fluids, fluids, fluids, but how much exactly? No worries, newFNP is here to provide the answer to that pressing question. As newFNP always says, there is no time like the present to review the exciting world of pediatric maintenance fluids.

Here's the formula:

First 10 kg: 100/ml/kg/day (aka 1000 ml if the kid is a full 10 kg - see how easy this is!)
Second 10 kg: 50/ml/kg/day
Each added kg: 20/ml/kg/day

For example, a 28-pound (13 kg) kid requires 1000ml + 150ml = 1150ml/day. Let's divide by 30 and tell the patient something they understand: No less than 38 ounces in 24 hours, buddy.

See, easy peasy! That is, if you have a calculator or are John Nash.

Oh, and newFNP is certain that everyone already knows to get a urine on these kids. A nice little quantitative measure of current hydration status. The whole "sunken orbits" is a little too subjective for newFNP. Maybe the kid was just not blessed with a doe-eyed countenance! Does that indictment really need to be a part of the permanent medical record?

Happy calculating!

Pet Peeves

There are a few things that turns newFNP off during the clinical encounter. And I'm not talking about all the patients who ask me about my marital status.

Nope, I mean the ones who open the door and stare at me when I'm reading another patient's chart in the hallway. Estimada paciente, do not go back into your room and leave the door open while waiting for me. Read the thoughtful en espanol educational materials that I have photocopied on cheerfully-colored paper on my own time and that will offer helpful suggestions to help you lose 30 [read: 50] pounds. I hate that you continue to stare at me while I read your chart in the hallway so as to garner a shred of an idea as to why you might be visiting me. I understand that you are waiting a long time for me. I promise that I'll be in ASAP. Now shut the damned door.

But even more than the patient-imposed open door policy, newFNP gets all bunched up when, after opening the door, she sees the patient perched on the rolling stool. I'm telling all y'all motherfuckers that I have two graduate degrees, a stethoscope and a white coat. I have earned the rolly stool. Who doesn't know that the rolly stool is for the one who writes the prescriptions? Move it, buster. If it's a kid, I let it slide because - hey- the rolly stool is fun. But adults get no love from newFNP is they steal the stool.

Why is newFNP so lame as to even give a fuck if the patient wants the rolly stool? A) It's a safety thing. I am positioning myself closest to the door in case you are a weird-o or mentally disturbed like the guy who stabbed Carter on 'ER'. B) I don't want to sit in the regular chair. Period. C) The rolly stool is mine. D) Respect. It's silly, but it seems disrespectful somehow. I'm sure it's not intentional but nonetheless, you go to your seat and I'll go to mine.

End of story.

The apple doesn't fall....

When newFNP was a student, she wrote a (fascinating and insightful) paper about parental loss in childhood, but specifically adolescence. It doesn't take a frigging genius to know that this is one of the most painful losses a child faces, that its consequences are potentially devastating and can be life-long. The legacy of that loss can profoundly shape the child.

Given that newFNP has such keen acumen, she should be incredibly prepared with all of the right words when a patient tells her that he or she has, in fact, experienced parental loss.

My 11-year old patient's mom died when she was 8 - complication of diabetes. My 11-year old patient is 243 pounds. Her acanthosis is pronounced. Can you see the trajectory?

She knows. I know.

She is scared. She is terrified to have her sugar checked because what will happen to her if she has diabetes? Will the same end meet her as met her mother? And she is only 11.

It is so complex. Her dad tends to give her whatever she wants because he cannot give her what she has lost. So she gets honey buns and Hot Cheetos. She is too young to know how to really do anything different. She is too scared to honestly talk to me (in 15 minutes) about her weight because of what it signifies.

This is the poignancy of family practice. This family is in crisis. They both need to make changes and they both need support following their loss. I want to give them the tools to mend their family as best they can. But 15 minute appointments. Damn.

I don't know if what I did was right, but I told her that I was there to help her and that I wanted her to know that there are people in this world who care for her, who love her. I told her that I would be there for her even when she wasn't sick, that she could come in just to talk if she needed to. I told her that my mom died when I was young because I remember thinking that I was the only person in the world who could ever experience such heart-wrenching loneliness. Shit, I hope that still falls within the confines of holistic care. Patients feel free to ask me about my marital status and parity, so I can tell other patients personal stories if they are relevant, right? I just wanted her to know that she had somewhere to turn and I didn't know how else to make her see that.

And now I need to find a childhood grief specialist. Who takes public insurance. Motherfuck.

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.

A Cure for the Obesity Epidemic

I've got it. It's a plan that will never come to fruition, but one I think has the potential to be quite effective. No, it's not the removal of sodas and Taco Bell, Golden Arches,Burger King and vending machines from schools. It's not more exercise or daily P.E. in schools. It's not 'you'll get Type 2 diabetes and have hypertension and dyslipidemia, all predisposing you to a big old MI.' Those are good ideas, by the way, great ideas even, but my proposed campaign is meant to have a visceral response, striking at the very core of insecurities all over the world.

(I love hyperbole.)

It's fair to say that all people have some degree of interest in their genitals, right? I mean, we have penis pumps, Brazilian waxes thanks to those evil J Sisters, circumcision, female circumcision as well as various nether-region accoutrement. Men can't stop touching their goods from infanthood until, well, until they die I guess. This obsession is the basis for my campaign.

My idea is this: let's raise the awareness of the 'hidden penis' and the 'fat vagina.'

I mean, does any guy want to exchange his average penis for a huge pannus? It's not even a fair trade!

And ladies have labiaplasty in order to have a perfect genital portrait. Not my patients, but I've seen the advertisements and if plastic surgeons can play off vag insecurity, then so can public health. So don't get a huge vag!

And after this awareness raising campaign, we can transition back to the more traditional interventions. It's worth a shot. The other methods sure as hell aren't working very well.

Take that, 911!

Yesterday, in the midst of uncontrolled hypertension and diabetes (see 'Rant'), the 7-year old patient in the next room was having dyspnea.

I swear, the kid looked fine when he walked into the clinic, but by the time I saw him in the room, his fever had shot up to 104.0, his 02 had dropped to 90-93% and he was sweating like a west coast native during a New England summer. The only thing missing was frizzy hair. In addition to these alarming findings, his eyes both got red and puffy. Not the way newFNP looks around grass and cats, but peri-orbitally he just looked wrong.

In addition to the fever, he also had rhonchi & wheezing so newFNP treated him to grape flavored Motrin, strapped him onto the nebulizer and put a cold pack behind his neck. In the back of my mind, I was wondering if I should treat him for the likely pneumonia or send his ass to the ED. And this is where the struggle of community health comes in.

The kid perked up, but still didn't seem A-OK to me. I was content to send him to the ED with his mom and three siblings, but they had no car. I asked her to call someone but no one was available to help her out. At this point, newFNP wasn't convinced that the kid needed an ambulance, but newFNP was also distinctly uncomfortable with sending him home.

As such, 911 was called to save the day. Of course, the kid looked super by the time the four paramedics arrived. As I recounted his tale, sounding like an idiot as always ("Um, I can't remember his BP - sorry"), the strapping, capable and tough paramedics looked upon newFNP as a nuisance, a burden, an embarassment to medical/nursing professionals everywhere.

Well, fuck them because the kid's mom called and told me that her son stopped breathing in the hospital. Now, I don't know if he de-satted or if he really stopped breathing, but he remains in the hospital as of now. All through the night I was wondering if I had over-reacted, but I am so thankful that I made the decision to send him.

Take that, hot paramedics! You think you know everything with your pecs and your biceps and your six-foot-three! Blow me.

Rant

NewFNP is tired today. When newFNP is tired, newFNP is pissy and easily frustrated. It's a familiar rant - the one I am about to share - but a rant I continue to feel the need to express nontheless.

If you are nearly 300 pounds, with a BP of 191/106 and a glucose of 425, don't fucking tell me that you are on motherfucking Jenny Craig or Weight Watchers or that you are Sweating to the Oldies. Just tell me that you had a Double Western Bacon Cheeseburger for breakfast and that you might just have a repeat for lunch, extra mayo and a large fries. Do not blow sunshine up newFNP's ass, especially sleepy newFNP. Because newFNP will hate you.

Part of the problem with being newFNP is that, as newFNP, you like to get straight A's & maybe one B in some bullshit class. Well, when you are my uncontrolled diabetic and hypertensive patient, I get an F. And it's your fault. Like a group project gone woefully awry.

I'm willing to work with you and even carry the burden of our group endeavor. But don't piss on my head and tell me it's raining. Oh, My Lady of Uncontrolled Chronic Disease, why must you torture me? You are too young for nephropathy and LVH, and you understand me because we speak in English. Yet you do not heed my sage advice.

And newFNP stayed up too late last night to be empathic newFNP to all patients today. That is a burden of the role. One must be on one's game, even when one is a crabapple. Therefore, newFNP must now toddle off to bed so as to be stellar tomorrow.

Because that patient is coming back. Balls!

She don't lie, she don't lie, she don't lie.....

I'm sure that if there is one question on the minds of newFNP's readers, it is this:

What the hell is up with the coke nail?

You all know what I mean, right? It's the nasty-ass long pinkie nail that men sport. I have yet to see a lady rocking the coke nail. Aside from the male gender prevalence, these are the other demographic details I have amassed.

1) Men of all ages feel it is appropriate to advertise their love of the cocaine via a long manicured pinkie nail.
2) Men of varying cultural backgrounds find common ground in the coke nail. Does newFNP sense an opportunity for coalition building amongst cokeheads? The Million Pinkie Coke Nail March? Better wear protective eyewear!

NewFNP will take this opportunity to judge the pinkie nail. Judgement: foul. People need to head to the cokehead nail salon and chop off that disgusting talon. Ugh. Just seeing it grosses me out.

If anyone has insight into the coke nail phenomenon, please e-mail me at newfnp@gmail.com. I must gain understanding into this disturbing and widespread occurrence. Is there an alternative explanation? Is it just to clean one's ears?

Help me understand this frightening trend. I beg of you, help.

Follow-up visit

So, my yeast ear lady came back today. Sure enough, the culture showed budding yeasts. And for those who are keeping track, Diflucan does in fact work on extra-vaginal candida infections.

But here is the crazy part. My patient was not only rocking otic yeast.

As I skillfully manipulated the otoscope to visualize the canal, I perceived an eerie green glow. Did she have Kryptonite in her ear? Did she melt some Play-Doh in there?

In fact, no. She had a pseudomonas aeruginosa. And Cipro Otic costs approximately $80. How it sucks to be uninsured with an uncommon gram-negative otitis externa.

A Tale of Two Fat Ladies

The tale has almost nothing to do with fat, although both of the ladies around whom the tales revolve were in the mid-300 pound range. No, these tales are far more interesting to newFNP than fat.

Tale One:

How many times can one person consume antibiotics for an ulceration caused by moist flesh rubbing on its neighboring moist flesh? The answer: a shitload.

My patient has had an ulceration on her left breast for years. It comes and goes, it's purulent then not, it has been the target of antibiotic treatment time and time again, none of which at the hands of newFNP. As newFNP has stated time and time again, she is a tight-ass with antibiotics. Rather than empirically treat and given her ongoing love/hate affair with Amox and Keflex, newFNP cultured said ulceration and sent it off to the lab. Bye bye culture!

Imagine my surprise today when, in the midst of 17 patients seen in the morning session, I see a lab result screaming 'MRSA' sitting on my desk. No wonder the 2-year course of antibiotics didn't knock that sucker out.

Aside: newFNP had never actually recommended a bra as a component of treatment for a patient until I saw that those pendulous breasts, each bigger than my head, were resting unsupported on the patient's ample abdomen. Rx: BRA!!!

Tale Two:

Religion is important to many of my patients. NewFNP tends to keep any spirituality, or lack thereof, to herself but listens respectfully when patients share their faith. NewFNP has even been known to encourage spiritual counsel in times of distress.

My kind and compassionate patient today has relied upon her faith to support her during a difficult transition from married to separated. Her faith is so important to her that she brought a photocopied reading to drink in during her lengthy wait at the clinic. All in all, a smart move.

As I was examining her, she placed the readings on the exam table behind her. During her lung exam, I glanced down and noticed the word 'Jews' in the selection. During a seemingly thorough, entirely benign and incredibly distracted exam, I came to learn that her religion teaches its followers that the Jews are indeed responsible for killing Jesus Christ. I was frustrated and saddened, yet said nothing. What is there to say?

When TV is the cure

Cold & flu season has struck my clinic and, as newFNP has up to date information on the latest and greatest treatment guidelines, I would like to offer these words of advice to all of the patients streaming in and out of my clinic with body aches, fever and malaise: stay the fuck home. Watch some Daily Shows that you have TiVo'd. Check out reruns of CHiPs or Dos Mujeres, Un Camino. For the love of god, sleep - but do not expose me, my staff and my patients with pneumonia, diabetes and asthma to whatever you have brewing! And quit asking me for antibiotics. You're not getting any.

It's not that newFNP doesn't sympathize with how crappy one feels when one has the flu. It's just that a guiding principle of public health is to reduce one's exposure to potentially hazardous conditions. Your partner's herpes are acting up? I can't think of a better time to abstain. Granny has a touch of the TB? Don't share a non-ventilated close space with her.

But, you see, this goes both ways. If you know that your penis is leaking green discharge and you need to take a percocet in order to pee, don't hit up your special lady or fella for sweet lovin'. And if you are fluish, please have the courtesy of limiting your exposure to others. Sure, your family will suffer, but does that mean the entire community must as well?

Oh, and if your penis is leaky, that is a perfect time to hit up the clinic for antibiotics. We'd gladly give you a Rocephin injection! With Lidocaine and everything.

But does it itch?

Ear pain. We've all had it, but I'd hazard a guess that we haven't all had the symptoms one patient was experiencing today. Last month, she was treated for otitis externa and has been using cortisporin otic drops. Steroid-containing drops. Her pain was intensifying over the past three days so she returned for follow-up care. In addition to her otalgia, she also had tender pre-auricular lymphadenopathy. Her past medical history is negative for diabetes, FYI.

Good ear looks good. Textbook, one might say. Affected ear on the other hand... I carefully looked in her ear and thought, "Now, if I were looking in a vagina, I would be quite certain that I was seeing yeast." Now, I do not come home to peruse Gray's Anatomy every evening, but I am confident that I know an ear from a vagina. But yeast? In the ear? Another first for newFNP. It was all I could do not to laugh as I used a vaginal wet mount swab to grab a culture of the ear funk. Ah, improv.

I treated her with Diflucan under the philosophy of what's good for the south is good for the north. I can't wait to get that ear wet mount back.

Oh, the learning curve

Did we learn about labs in school? I don't think so. I think that there should be an elective about lab result interpretation. Mind you, newFNP attended a well-respected institution, but has somehow made her way through without having a good understanding of lab results. Don't think for a minute that I can't interpret a CBC, because I can, but when you start throwing a jacked kidney my way, I am flat out lost. When there are too many numbers in the 'abnormal' column, my eyes glaze over as though I am back in C.O.C.

Case in point. I had a patient last week who was an interesting looking little guy. 65 years old. First name: Latino. Last name: Asian. Not a common combination in my 'hood, but stranger unions have certainly happened. Skin was a little yellow looking, belly was really round. Maybe I should have picked up on that, but if I stopped to really consider every weird-looking, rotund patient who crosses my path, I would have no time to peruse the internet for Sigersons and flattering Theory trousers.

My patient also had a very chatty wife who accompanied him to his physical and freqently interjected her own tales of health woes throughout his exam. NewFNP can only handle so many distractions and annoying chatty wife was throwing me off my game.

Long story short, Mr. Latino Asian likes to drink. Hell, newFNP likes to drink, but not like this guy! I drew his labs and got this, amongst many other abnormal values, back:

Albumin 2.6 (3.8-5.0) So - low, right?
Bilirubin 6.5 (0.1 - 1.5) Let's call that one 'elevated.'
AST 113 (1-45) Remember - Alcohol, Statins, Tylenol
ALT 56 (1-55) Ding ding! Most normal lab value goes to ALT!!

Another provider took a nano-second glance at the labs and said "Oh, AST 2 times the ALT is pathognomonic for alcoholism." She then glanced at him and said, "He is clearly cirrhotic." He is??? Well, shit. If I would have known it was so obvious...

The problem is that many things need to be so flagrantly obvious. Your blood pressure 210/105? Buddy, you are one hypertensive motherfucker. Blood sugar in the 600's? I'll lay my money on diabetes.

But other seemingly obvious diagnoses escape me, to say nothing of the not-so obvious diagnoses.

On the bright side, I really feel like I have my charting/prescription signature nailed.

"I" statements

We are all taught to speak to patients in "I" statements, especially when confronting something that is potentially uncomfortable. This may include, "I notice that you have bruises in the shape of fingers" or "I see that you weigh 498 pounds" or "I can see that you are upset by your gonorrhea infection and need for a painful Rocephin injection."

However, sometimes newFNP's "I" statements escape her. This week, it was because I wasn't sure what I was (not) seeing and feeling. When I was in school, I had a similar experience in which a patient, upon whom I was gearing up to perform a DRE, assumed the position, thereby exposing her tail. "I see you have a shaggy tail. Has that always been there?" No, no - I didn't say that, but any sensitive statement I may have been able to come up with was vanquished by the magnitude of my shock. Why didn't they tell me in Advanced Health Assessment that I may happen upon a tail? I was ill-prepared.

I was also ill-prepared for my 36-year old father of three with tiny, hard testicles as well. Now, although newFNP does not possess said equipment, she has once or twice been familiar with those who do *and* has seen enough in the clinical context to know that they should be more like matzo balls than walnuts. So, what was I to say?

"I notice that your testicles are like raisins. Were they ever prune-like?"

"I feel that your testicles are firm like marbles... and not much bigger. Were they ever more like Everlasting Gobstoppers - the big ones?"

"I see that your testicles are essentially non-existant. Do you really have three children?"

See? It's hard to have good "I" statements on the fly. Part of the reason it was difficult is because I was uncomfortable telling this gent that his balls were weird. Is there a guy out there who wants to hear that? In Spanish. In my crappy-assed Spanish.

"Sus testiculos son demasiado locos." Bad, bad newFNP. Must learn sensitive Spanish!

May-December

In the spirit of "Shopgirl," in which a fresh, vibrant Claire Danes dates a geriatric Steve Martin, I offer this thought. It's not only the aging Hollywood set who enjoy a youthful romp with a partner half their age. Not at all. This week, a 76-year old patient told me that he had 10 children, the youngest of whom was an astonishing 5 years old. A quick mathematical calculation told me that his wife must not be his age. Yes, my patient's first wife died when she was 70. I don't think that the mourning period was a long one before he nabbed his currently 38-year old wife.

When I think of dating someone nearly 40 years my senior, I think of one thing and one thing only: money. Now, I could be wrong, but my sense is that this 38-year old woman is not rolling in an A8, nor is she sporting a Harry Winston, nor is she head to toe in D&G. But even if the hottest rich 70-year old in the world wanted to date me, he would still be 70. Whatever works for my patients is cool with me, but I am, quite frankly, grossed out by the thought of shagging a grandpa. Do you think she has to inject his hips with cortisone so that he can lay the sweet moves on her?

Guh-ross.

This just in....

There are few things that newFNP likes to ponder less than pelvic floor disorders and urinary incontinence. I was, however, at a conference recently and found myself desperately and vigorously performing Kegel after Kegel in order to stave off a sad, sad future. In fact, I'm doing my Kegels now and you should be too. We should all have the lactic acid build-up normally associated with leg presses, 10-mile runs and push-ups. Because, baby, I do not want my uterus heading south for the winter. Nor am I relishing the thought a future with rubber mattress pads.

The reason I am exercising my vagina 100 times more than my abs or glutes is that the keynote speaker at the conference presented data from the WHI that stated that a full forty-frigging-one percent of women had some form of prolapse. Hey, maybe your bladder is just sneaking posteriorly into your vag, but maybe your cervix is at your knees. I don't want either. Kegel, Kegel, Kegel... feel the burn.

Sure, childbirth makes a difference in the likelihood of anatomical slippage, but guess what? It's the first kid that makes the most difference and, I hate to say it, but nulliparous women may share the prolapse experience with their more fertile sisters. Thinking of scheduling a c-section like your gal-pal Britney S.? Well, that's not gonna save you either. So go ahead and have your babies in whichever way you choose, but Kegel it up, ladies. And do your best to lose the pregnancy weight, because overweight (waist circumference >88cm) isn't going to help matters.

The same goes for incontinence. Parity, obesity, hysterectomy... they all will have you running to bathroom, stifling your laughs and hoping that your little cough goes away quickly. Apparently, 50% of us will have incontinence. Son of a bitch, does that ever suck. Kegels. 30-35 exercises per day. I don't want vaginal hypertrophy, but I'm thinking the more, the merrier when it comes to incontinence prevention.

Diabetes also plays a role in incontinence due to the nerve damage. So, let's see what sucks about uncontrolled diabetes. It's not the death so much, in my opinion, as all the horrible effects of the disease. Blindness, kidney dysfunction, erectile dysfunction, amputations, thick toenails, heart disease and incontinence. None of those are my idea of a good time.

In other news, updated CDC guidlelines, due to come out next year, state that we should no longer be prescribing 2g of Flagyl PO for BV. It's just not efficacious. It's all about the 500mg PO BID x 7, 5 nights of Metro-Gel or 7 nights of Clindamycin cream. So give your ladies a break and treat their BV effectively, OK?

Melting

NewFNP is somewhat cynical. Dry. You know the type. Not someone easily moved by cuteness.

However, newFNP is not made of stone. Today a little girl, around age 7, was at the clinic with her mom, who had an appointment. After I had finished the appointment, which involved tears, labs, referrals and the ED, the little girl grabbed my hand in hers, kissed it and said, "Thank you for helping my mommy."

It was the best moment of my life as newFNP.

One for you, one for me

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Social history

There are certain questions that I have not once asked any of my health care providers. These questions include:

1) Are you married or single?
2) Do you have any kids?
2a) Why not?

My patients, however, ask me these questions with astonishing frequency. I'm talking daily to multiple times daily. On Friday, I'm quite certain that a record was set. If I had to hazard a guess, I'd say that fully 40-50% of my patients asked one or more of the previous questions. One older gent went on to ask, "What kind of men do you like: Mexican or American?"

He then offered this little bit of dating advice. "You know what you should do?" he said. "Go to dances." This is the same exact advice that my grandmother gives me, wistfully thinking back to the WW2 era dances, one of which she attended and met my grandfather. I told him what I tell her: I don't like dancing. Why would I want to meet someone who does? I'm sure that I can find many ways to disappoint the man of my dreams and I don't need to add fuel to the fire with the ole "I like to dance" bait & switch routine. I like to read. I like to sit on my couch, drink French Roast, and read. I meet a disappointing number of hot, smart, funny guys (n=0) conducting this activity.

So, yes, my patients frequently ask me about my personal life. And, going against what my professors might counsel, I answer them - mostly. I don't tell them that I don't think I want kids because my sense it that is akin to telling them that tortillas aren't breakfast food for me, or that I have no interest in soccer (or any other sport except mine for that matter). I think it's appropriate to share to the extent we are comfortable with our patients. Part of why I am an NP is to remove barriers to patient care. I hope that my being a person and not just a fucking hot-ass girl in a white coat will facilitate that. I want to build relationships with my patients in an effort to keep them healthy and to keep them satisfied with the care they receive at our clinic.

Plus, it's like having a nice Jewish family, meddling in my personal life, right here in the midst of my Latino patient population. L'chaim!

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.

Picky evolution

NewFNP is no proponent of intelligent design. Anyone who has taken a college-level biology class can understand why when you think back to the markings on animals, moths, insects, etc. Others may remember that from high school, but newFNP had biology 1st period and was no fan of 7:50AM classes. It's true, newFNP was a big 1st period ditcher. Anyway...

One of my non-scientific proofs of the theory of evolution is that I understand the desire to pick. Have we all seen the PBS shows in which the mommy gorilla picks crap off of the baby gorilla? I loooooooove picking. It's gross, but true.

I began to understand the process of natural selection and its relationship to picking this week in clinic. This understanding has made me think twice about my love affair with the pick. Here is a mathematical equation to explain what I saw this week:

folliculitis + (machinist + greasy, dirty hands) + picking = 2(abscess)

And the funny thing... what did he call it? A rash. Noooo, not a rash my friend. A pus pocket, a purulence pond, a perilous post-picking problem.

Must. Keep. Hands. Off. Blemishes. Bumps. Et cetera.

Ayyyyy me duele!!

Culture. We all have it. In mine, stoicism in the face of pain - emotional or physical - is valued. I'm not saying that's right, I'm just laying it out there. Apparently, an ever-elusive perfect weight is valued as well as newFNP's family always has a comment about weight during any visit - too much, too little, but not-as-of-yet just right. Anyway, internal demons aside, newFNP is one to grin and bear it, pull herself up by her bootstraps - bootstraps which will one day bear the Prada insignia if all goes well.

This cultural bias and placement makes it exceedingly difficult for newFNP to stomach the (perceived) histrionics of pain during exam. The vocalization of "Ayyyyyy, me duele.... aqui, ayyyy me duele!! Doctora, me duele!!! Ayyyyy, dios mio, me duele!!" It makes me crazy. I don't doubt that it hurts, but I would have to be carrying my own detached arm to the doctor to complain half as much as these women do. A good fashionista pal pointed out that perhaps some of these women have no other place to vent their pain - a good hypothesis, I believe.

Cultural bias takes on other forms as well. Today, a 40-year old patient came in for a pap. She had sex last night - no condom. Generally, no condom = no pap, but her case was different. This woman has had sex virtually every day for the past 26 years with her husband, whether she wanted to or not. According to her, she "rarely" wants to. According to him, it's her responsibility. Even though she complies with this, again, nearly daily activity, her husband has had many extra-marital relationships and has, according to my patient, transmitted chlamydia, gonorrhea, herpes and pubic lice to her throughout the course of their relationship.

How is that for insult to injury? Sexually transmitted infections through forced sex. Incidentally, she denies IPV. Hmmm..... can you see where newFNP's culture is sneaking in?

I asked her if she thought it was okay for her to have sex with her husband when she didn't want to. She responded, "No se." If she doesn't know, how am I supposed to know? I know what the answer is for me, but is this a universal truth or a newFNP truth? Her affect and her tears told me what she really believes, but I could only offer her the tools available to us: our counselor.

I am so glad I got to come home to my apartment, no abuse, maple yogurt and Boston Legal on the tube. I wonder what her night will be like.

Incidentally, in the area where my clinic is located, I have noticed a cultural value of slow-assed fucking driving. Ayyyyyyy, me duele, the slow drivers. Mueve!

I hate it when I'm stupid

I think that when I'm overwhelmed, I have that whole "forest through the trees" problem. I saw a patient this week (several times) who I diagnosed with Type 2 Diabetes. Her blood sugars were in the 3- and 400's. I was diligently attempting to decrease this number when I noticed that she also had a Hgb level of 6.3. I provided the following to her:

• diabetes education regarding meds, sequelae, dietary changes, exercise
• prescriptions for appropriate meds and insulin in the office
• Ferrous sulfate 325 mg/day
• referral for colonoscopy
• stool cards x3

And, in all of that, I also provided utterly inadequate care. Why? I didn't get a fucking CBC! How did I miss that? Total cholesterol? Check. Hgb A1c? Check. CBC? Nope, not so much. Ugh! Why am I still a jackass? The beauty is that every time I feel like an ass, I know that the shame of missing something so easy will cause me to never make that rookie mistake again. And I am a rookie, after all. I just don't like to play like one.

Achy Breaky Heart

A crazy thing happened today. I saw the most patients I have ever seen in a single day (n = 28) and I left the clinic at 5:00 PM on the nose. It was divine. I am in a state of joy bordering on beatitude.

I did, however, send a patient to the emergency room. I like to have both the calm and the storm, I guess. Here is why this man had a ride with the paramedics. He had chest pain, dyspnea (worse when supine, so I guess technically it was orthopnea) and had diagnosed left-sided heart failure last year that resulted in him receiving a pacemaker. His father died from heart failure at age 54. And did I mention that, despite treatment with 80mg TID of Lasix, he had urinated exactly once (4 ounces – he actually measured) in 48 hours?

Now, I must confess that I partially sent him because I was scared, the only provider in the office this afternoon, and I knew that his history and symptoms were both serious and beyond my ability to care for. I think that it was the right decision. He was overweight and his exam was unremarkable, but as I’ve previously mentioned, ausculatory exams on obese persons are exceedingly difficult. Did I hear crackles? I did not. Nor did I hear normal breath sounds; I heard faint breath sounds and faint heart sounds. His abdomen was huge. Was he holding fluid in there? I don’t know, but the doctors at the emergency room will.

For those students/new practitioners who are familiar with the lower extremity edema/DOE/chest pain presentation of heart failure, please allow me to point out that this picture often points to right-sided failure. Left-sided HF is sneakier. I was too freaked out to think about that until the paramedic mentioned it, leaving me to feel like a huge jackass. Whatever – my ego will survive and I am the wiser for it.

Here are some tidbits to refresh and/or inform:

Signs of HF include:
DOE/PND/orthopnea
Cough with or without frothy sputum (yeah – gross)
Abdominal pain +/- nausea
Constipation (who knew??)
Exercise intolerance (I’d hazard a guess that 90% of my patients have this as they never exercise)

Symptoms of HF include:
Fine crackles, generally bibasilar
S3
Edema
JVD
Tachycardia
Hepatomegaly
Pallor or cyanosis

However, Uphold & Graham point out that “[in] left-ventricular systolic dysfunction, signs and symptoms are not reliable indicators or cardiac functioning; patients with severely impaired ventricular performance may be completely asymptomatic until they overexert themselves…” Thus, the ED visit today.

Which reminds me… the paramedic asked me, as I was standing there feeling like a buffoon, if any of the patient’s medications were constipating. A) I don’t fucking know for certain but probably not and B) constipated or not, homeboy has essentially not taken a leak in 2 days and has both a personal and family history of cardiac disease. Can we deal with the poop later, please? When I’m thinking of priorities, it goes something like this:
1) heart failure
2) poop

Twenty-eight patients. I think my days on easy street will be coming to an end. I exceeded my goal – set by the clinic manager - of 22-25 patients/day. Crap.