Ahhh... cable TV

NewFNP likes to fancy herself as healthy, but here she is - sick again. NewFNP attributes her illness to being exposed to all manners of rhinoviruses day in and day out and believes wholeheartedly that it is only the most virulent of said viruses that tend to knock newFNP on her ass. Which is where she has been all weekend. On the couch, flat on her ass, in and out of consciousness, thanking God that her boyfriend had the good sense to buy a huge flatscreen TV so that she may be entertained by the likes of Dirty Dancing, CSI and Caddyshack.

Nobody puts Baby in a corner.

NewFNP did take some time during her convalescence to think about her current employment situation. She reviewed some physical assessment texts and thought about where she might be taking her career. As we all know, her attitude is in the toilet. However, newFNP would like to change that and certainly does not want her career to follow that path.

But here is why newFNP's attitude sucks.

Sometimes people just break newFNP's heart. When newFNP hears about food insecurity from a featherweight 22-year old man, it just makes her emotional. Imagine leaving one's country to come to the US, in hopes of a better existence, and not being able to find adequate food. Of knowing that you have latent TB, but not being able to afford the $10 medicine to avoid active TB infection. Of finally securing a job, but working six days per week and not being allowed to leave early to get to the clinic. There was something more about this patient, though. His modesty, his sincerity... he really touched newFNP.

Then there are the people who make newFNP want to scream. This week, a patient told newFNP that no matter how much he weighs, he never changes in size. In fact, he claimed, one time he lost one hundred pounds, but still wore the same sized jeans. "One hundred pounds?", newFNP verified. Confirmed. One hundred pounds and still a size 42 waist. Diagnosis: delusional liar? Reality challenged? How is newFNP supposed to help someone who has clearly lost touch with all that is real? NewFNP notices that her trousers are roomier of she loses 1/100th of a pound.

And finally there is that old chestnut about support staff not providing support. NewFNP does not want to micromanage, nor does she have the time to do so. But when newFNP's reputation is on the line, you bet that she will be all over the staff's asses in order to get things done. You betcha that newFNP can find 30 seconds in between patients to ask if phone calls have been made and abnormal pap logs have been updated.

A friend of newFNP's recently noted that he felt that newFNP sometimes feels anger toward her patients. NewFNP disagrees, but she certainly does feel frustration toward many patients. Quite simply, how could one not feel frustrated given the challenges one faces in community health and probably in all healthcare settings?

Working through these frustrations is one of the challenges that newFNP faces. Sometimes she is great at it, sometimes not so much.

Unqualified

NewFNP works in the poorest service area within her county. Almost every single health outcome indicator (overall mortality, teen births, infant mortality, obesity, cardiovascular mortality, insurance coverage - you get the picture) is the worst in her entire huge county. Her patients are exclusively covered by public health insurance, if at all.

So when newFNP has a patient who has some wealth accumulated, she finds it, frankly, a little surprising.

For instance, when newFNP asks her patient if she has health insurance and her patient responds that, no, she doesn't qualify for health insurance because she owns her home, newFNP is surprised. NewFNP's patient's net worth is greater than that of newFNP, yet newFNP is working, paying off five years of grad school loans and going home to her rented apartment, albeit a sweet-ass apartment with hardwood, washer & dryer and arched doorways located in a chic and safe area of her city. Perhaps newFNP will one day achieve the dream of home ownership herself, but she is currently unwilling to sacrifice her HMO and 401(k).

NewFNP's landed gentry patient must think that state-funded insurance is the creme de la creme, because she asked newFNP if newFNP "qualified" to receive it. Almost! If the state took newFNP's loans into account, she just might qualify for public insurance and section 8 housing!

At any rate, newFNP believes that this speaks to the need for universal health insurance. Should newFNP's patient have to sell her house in order to qualify for public health coverage? Does being a homeowner make newFNP's patient a woman of means? Might newFNP's patient end up costing the public health system more money if she can't get the care she requires? No, no, yes.

NewFNP does not like to think about how much longer we have until the next presidential election, but is she ever hopeful that the pendulum will be swinging left!

A community health fairy tale

NewFNP works for an organization that has four clinics. She is generally at one site, but floats from other sites time to time. Some might say that we are all sister clinics. Others might call one clinic or another an evil step-sister.

As newFNP's readers know, newFNP's clinic is down one full-time provider. The other NP works three days per week. That leaves newFNP alone two days per week. So fine, newFNP has to go it on her own. NewFNP has to fill out the paperwork for all of the kids needing school physical documentation, organize the type 2 diabetes group, help the HR director re-apply for the HPSA score and write letters for patients applying for disability. By the way, is having dyslipidemia a disability? Hmmm, newFNP thinks not. Denied!

Did newFNP mention that she has zero hours of administrative time during her work day?

All this to say that, frankly, newFNP doesn't need anything extra. NewFNP most definitively does not need another clinic, her organization's biggest clinic, sending her a walk-in s/p abscess I&D wound care patient. And furthermore, newFNP does not need that patient to walk-in without a either a courtesy phone call from the dickhead at the front desk of the other clinic or a copy of the patient's registration info and progress note faxed from the clinic.

Why can't other people understand that taking five minutes to extend professional courtesy makes a difference? This is what continually floors newFNP about working in community health. Some of her colleagues just don't have common sense, nor do they think to extend courtesy to each other. Certainly a phone call is a chance to express thanks for the extra work, to give a heads up that you might be keeping your staff over an hour late due to the complexity of the walk-in patient and that you will likely be missing a date with your boyfriend.

But no. In walked newFNP's patient with a 2-inch gaping wound in her buttocks, covered with approximately 800 bandages and 35 rolls of tape. It took 15 minutes just to get the bad dressing off this poor lady's irritated skin. After diluting the wound with one liter of diluted hydrogen peroxide, newFNP packed her patient's lovely lady lump with three feet of iodoform. Three feet. During this process, newFNP's patient told her that the other clinic sent her because newFNP's clinic was bigger, that the evil step-sister clinic was closing early and that they didn't have the supplies to do the dressing change.

Interesting phenomenon indeed. The clinic had the supplies to slice open this woman's butt, pack the wound and cover it, but not to check on her healing and change her bandage.

It's one thing to have patients dumped from other clinics, but to get screwed by one's own colleagues! That just leaves a bitter taste in newFNP's already tart mouth.

Bathtub safety

NewFNP has a hunch that it is going to be a grand day at work when, driving to work at 8AM, she sees no less than five commercial sex workers standing on consecutive corners, white patent faux leather thigh-high boots, Daisy Dukes and Huggy Bear caps-a-plenty. Is there no vice squad in newFNP's major metropolitan area? Can the lady walking down the street in a tee-shirt and no pants or underwear find it within herself to cover her huge ass? What the fuck?

Seriously people. Can't we all agree that there are certain things that newFNP, as well as the majority of the rest of the world, do not need to see except at the movie theater or on C*O*P*S? There is only so much vice that newFNP can tolerate so early in the morning. This morning exceeded newFNP's quota.

So, hours passed with no obvious prostitution, leading newFNP to think that her day was normailzing, when newFNP was saw the chief complaint of "hurt her vagina." Now, newFNP is no stranger to curiously worded CC's, such as "little ball on the peanuts, " "soap in the right eye x 9 days" and "cough and flames x 2 days." What does newFNP have, a dragon for a patient? So, clearly, "hurt her vagina" isn't the oddest CC, but it's no "med refill" either.

Apparently, newFNP's 200-pound patient had slipped while exiting the tub. Her fall was broken by the tub wall, with her labia bearing the brunt of the force. Her left labia majora to be exact.

NewFNP uttered the words "oh shit" upon seeing her patient's horribly swollen purple labia. It was the size of newFNP's fist. It looked like a seashell. NewFNP imagines that she felt what all men feel when they see another man take a hit to the testes. Youch! Again, newFNP did screen for abuse - none. All of the pelvic bony structures were intact and the patient had full ROM at the hip, thus no x-ray for this uninsured patient.

Ice. Ice. Ice. Ice. Ice. Frozen peas baby. Mold 'em to your downstairs. Motrin 800mg TID with food. NewFNP thinks that pelvic rest is an obvious plan, but said it nonetheless. A little prayer that this will resolve quickly for the patient.

Man, oh man. What a day.

NewFNP's patients need the ERA!

Gender equality has yet to make it to newFNP's patients. Sure, in our practice, the medical and dental directors are both women, as are the CFO and COO. The majority of the providers are female. NewFNP can't imagine that any of them go home to loser husbands who sit on the couch, drink beer and watch TV.

Yet newFNP has patient after patient tell me that they can't find a moment for themselves, that they care for children and homes all day long, only to care for children, homes and partners once the men come home from work. And these women have complaints of fatigue, dizziness, "low blood pressure," and sadness.

And they have no friends. NewFNP asks about friends/support systems, but these women don't have them. NewFNP screens every patient for IPV, but the majority of these women deny abuse. They are just socially isolated. If newFNP didn't have her girlfriends, oh man, that would be a grim existence indeed.

Now don't everyone go and write newFNP, telling her that she is naive and all of these women are abused and denying IPV. Please. NewFNP doesn't screen just once and she gets that it takes more than once to gain confidence. Some of these women will disclose abuse; others are just married to beer-stained couch cushions.

NewFNP knows that we are supposed to be culturally sensitive, but newFNP finds it pretty fucking difficult to be sensitive to husbands/fathers who are as lazy as tree sloths. Yeah, yeah, these guys work all day, but so do their wives. Caring for children all day long is exhausting. How much pretend play can one engage in? NewFNP isn't talking about in the bedroom now, but speaking of... Is it any surprise that these women have no sexual desire? NewFNP thinks not. In fact, newFNP is hard pressed to think of a woman who is going to want some sweet lovin' if all she does is work around the house and see her husband watch WWF while sipping on a cool Pabst Blue Ribbon.

NewFNP had an awesome 28-year old patient today who is a mother of four. She does aerobics most days making her a clear outlier in newFNP's practice. Her husband would like another baby, mostly, she believes, to keep her around the house more. She told him that is would be a cold day in hell before that happened. NewFNP felt so proud of her!

Now newFNP is all riled up and needs to see if her boyfriend did the dishes or made the bed or did something today!

A personal tale

It should be no news to newFNP readers that newFNP's schedule is busy, overbooked, conducted in Spanish and often overwhelming. Given that, little personal difficulties may cause newFNP to experience her work stress on a continuum ranging from extra-stressful to unbearable.

Some examples.

A lone pimple: extra-stressful.
Bad hair day: pretty much every day, thus no added stress. Thank goodness for My Little Pony-tails.
Forgotten Nalgene: dehydratingly stressful.
Fight with Punjabi boyfriend: extra-stressful, that gaddha.

So imagine what real personal trauma might do.

NewFNP was raised by her maternal aunt from the age of 14, when her mother died suddenly after suffering a cerebral aneurysm. NewFNP's aunt, like her mom, was a single mom with two children. NewFNP's cousins are like her brothers. They snowboarded with newFNP, they white-water kayaked and rock-climbed together.

Two months before newFNP finished her studies, her older cousin was diagnosed with glioblastoma multiforme. She spent the summer after finishing her MSN with him, driving him to radiation every day, watching The West Wing on DVD and eating take-out Mexican and Baskin-Robbins. Last week, he started hospice care. He's 35. Thirty-fucking-five.

NewFNP spent last weekend holding his hand as he walked down the hall, paralyzed on his left, unable to walk alone. She held the container for him to urinate into. She sat by the hospital bed now in his bedroom while he slept. These intimacies that nurses share... well, newFNP has never shared them with another family member. While his mom does this for him on a daily basis, the last time newFNP spent time with him, he was walking alone. He wasn't asking newFNP about his impending death. He wasn't asking about what would happen when he could no longer walk or swallow.

NewFNP has a sweet patient now who had the tip of his finger traumatically amputated by a soccer cleat last weekend. He comes in for dressing changes and evaluation. It's a quiet appointment: cleaning, wrapping, assessing for re-growth of tissue that resembles a finger.

On Monday, newFNP could see him mourning the loss of his normal finger. Cleaning, thinking, Bacitracin-ing, fighting back tears, wrapping, mourning.

The odd thing is, in the midst of experiencing sadness of such depth that she cannot imagine it's resolution, newFNP has been surprisingly peaceful at work. It's not that she doesn't care. It's just - well - newFNP doesn't really know what it is.

She just can't leave the profound sadness at the door.

The real Dr. McDreamy*

NewFNP's clinic is going through a real change.

As of Monday, newFNP's supervising physician is gone. Over the past 18 months, this woman has been there for newFNP to educate, to support, to encourage and, at times, to commiserate. She is so good with patients that she could be an NP! And she was a huge advocate for the providers.

NewFNP has felt her loss frequently these past three days, perhaps most often when she was seeing Dr. Awesome's patients whose appointments the receptionists had neglected or otherwise failed to cancel. One example of this was when newFNP saw three scheduled 8:30 appointments today - 2 of Dr. Awesome's & 1 of her own. Another example was when she saw a physical scheduled for 3:30PM at 5:10PM. Did newFNP mention that this patient has fibromyalgia? Well, she does. 5:10PM - starting time.

Has newFNP mentioned recently that her clinic closes at 5PM?

Scheduling consequences aside, the most horrible thing about losing Dr. Awesome is that a great ally, a terrific leader, an inspirational provider and a physician who doesn't crawl up her newFNP's ass is gone.

And why is she gone? NewFNP thinks that her chronicle of the past year and one-half suffices for an explanation.

-----------
*newFNP has never seen Grey's Anatomy, nor does she endorse super-skinny girls with big pouts or homophobia.

Thar she blows

NewFNP loves derm. Paring down and freezing off warts - love it. Pityriasis - fascinating. Acne - please let newFNP help. And don't get newFNP started on Retin-A. It is her second favorite medicine after the Pill. In fact, scratch that. As newFNP is in her thirties, Retin-A is usurping the Pill's position as #1 medicine of newFNP's life.

Yes, newFNP loves derm. In fact, prior to getting master's degree #1, newFNP toyed with the idea of going to beauty school to be an aesthetician. What a cushy job. Soft music, aromatherapy candles, Sothys or Peter Thomas Roth product as far as the eye can see, comedone extractions.... ahhhhh. Well, newFNP didn't even have the chance to be a beauty school dropout. No, she pursued a career allowing her to benefit humanity in a different way. Who knows, however, what the future holds with the rise of the medi-spa.

In newFNP's clinic, she does not have a lot of opportunity to practice derm. Sure there are plenty of abscesses, but one cannot deny the olfactory component of the I&D which detracts from newFNP's overall satisfaction with the experience.

Enter the epidermoid cyst.

It's like Christmas and Hanukkah all rolled up into one for newFNP. Gross as it may be, there is something very gratifying about expressing 80,000 pounds (give or take) of sebaceous material from a huge cyst. It helps to have lifted some weights prior to the expression of said contents because one truly does need to apply a good deal of pressure. And newFNP would encourage all epidermoid cyst excisers to get the sac wall out, for the love of all that is holy. Sure it would be fun to go through the process all over again, but the patient may feel some dissatisfaction.

For a great article about protecting oneself and staff from the potential spraying contents and for an overall "how to," check out: http://www.aafp.org/afp/20020401/1409.html. Very helpful.

It doesn't take long

The first few days of work after returning from a two-week vacation, newFNP had a sort of Teflon Don-like armor, protecting her from all of the bull crap that had been bogging her down prior to her departure. NewFNP was so well-rested after her vay-cay, she felt like she had received a bull crap vaccine. She smiled, she enjoyed her patients and her relaxed demeanor was remarked upon by many patients and staff, including the C.O.O. In fact, more than one person asked newFNP if she had lost weight! NewFNP must have looked good!

Then, on her 3rd day back in clinic, newFNP began to notice that labels were missing from charts, that blood pressures weren't being recorded, and that her schedule was overbooked. Her M.A. lied to her face at 5:20 PM. The bull crap vaccine must not confer 100% immunity! GSK and Merck, where are you when newFNP is in need?

NewFNP didn't appreciate that there was a ratio at play here: for every one week of vacation, one may expect one day of immunity from the bologna regularly experienced in community health. After that, the protective effect wanes, and how!

And nothing will make that armor disappear like another provider going on vacation and the front office staff both neglecting to cancel her many appointments and allowing many of her patients to be seen despite newFNP having a full schedule herself. Yes, a 34-patient day pretty much wipes out any glow newFNP may have returned with. During her morning commute, newFNP is again fantasizing about quitting.

She is at the 50% mark of her service commitment.

Fucking hell. Another 18 months to go.

NewFNP felt like a rock star today, returning to the clinic. The floors were waxed, the staff gave newFNP hugs. NewFNP had to wonder if she found her way into the wrong clinic!

Ah, but then newFNP saw that the C.O.O. had scheduled her to work two six-day workweeks and she knew that she was, in fact, in the right clinic after all. That fucker.

And - just like that - newFNP was back at it.

After a year and a half in practice, newFNP finds that she is less and less frequently surprised by her clinical encounters. Today, however, was an exception.

It is no surprise that a woman who has had one lifetime pap twelve years ago would feel apprehensive about assuming the position. It is also no surprise that said woman would adopt that "straight leg, buns firmly planted halfway up the exam table" position when readying herself for the pap. In newFNP's practice, it is a little surprising to see a 32-year old woman with only one child (although actively trying for more since her first birth), but not so surprising as to merit a second thought during the patient's first visit on a busy clinical day.

What is surprising is to get the speculum placed and see an IUD string protruding from the os when the patient is quite clear that her birth control method is "condoms sometimes." When newFNP questioned her patient about the IUD, the patient stated that she had received the IUD after the birth of her 12-year old son, but was told that she had expelled it when she went for her one-month check up after insertion. Surprise! The 12-year old IUD is still contracepting! Well, it was until newFNP yanked that MF-er out.

What is even more surprising about this encounter is that less than 24 hours prior to experiencing it, newFNP received an e-mail from a friend from graduate school stating that she had the exact same experience. WTF! NewFNP knew that clinic encounters came in waves, but she didn't know that these waves cross county lines! What a phenomenon!

Flying high

If newFNP can share only one pearl of wisdom with her readers, let it be this: Coach to India is not the way to fly. NewFNP highly recommends the exit row for those who work in community health and cannot charge business class to their already balance-ridden credit card.

Aside from that, newFNP recommends India wholeheartedly. And acidophillus - take acidophillus while vacationing. And bring TP to all public loos.

Back to the clinic tomorrow morning.

NewFNP is no Pollyanna but...

Connoisseurs of newFNP know that she is prone to cynicism, to sarcasm and, sometimes, to frank exasperation. Well, newFNP is attempting to focus on the positive, to adopt a glass is half-full perspective, to be understanding.

For instance, just the other day, newFNP was leaving the loo, thinking to herself how grateful she is to work in a true family practice clinic. There are no internal medicine, pediatrics and gynecology clinics. No, newFNP jaunts from an elderly, obese, illiterate, non-compliant diabetic patient in room 1 (less fun) to a three-day old baby in room 2 (more fun). It is a lovely way to practice and newFNP does not get too bogged down in pediatric URIs or geriatric DM.

Another fashion in which newFNP has attempted to utilize the power of empathy is to attempt to understand the emotions and thought processes behind her patients' actions.

Consider - if you will - the case of the woman with the itchy scalp and hair loss. To newFNP, it might seem simply ludicrous and frankly dangerous to self-treat with topical Clorox bleach. But to her patient, perhaps the use of said laundry brightener/toilet cleaner was an act of sheer desperation, allowing newFNP to truly appreciate the urgency of the scalp situation. OK OK, it did take newFNP two days of incredulousness to gain said insight, but she is working on it and attempting to grow professionally.

She is also trying not to pull her hair out and get shipped to the psych ward before her contracted term is up. If she can pull it off, newFNP will have what is known as a "win - win" situation. Fulfilling employment on the one hand, significantly less student loan debt on the other.

newFNP couldn't agree more

In general, newFNP's clinic reserves Fridays for pediatric well-visits and follow-ups. However, as we are not complete a-holes, we do let an occasional adult in for pressing health issues.

NewFNP was treating a lovely 34-year old woman today for a UTI when she said, "You should be a model, not a doctor." True, so true - doctor/nurse practitioner distinction aside, of course.

Who looks pregnant now, motherfuckers?

When it's good to be newFNP

As newFNP's readers know, newFNP has her good newFNP days and her bad newFNP days.

NewFNP was so thankful today to spend 10 minutes educating the mom of a 12-month old about why we are changing him from QID Albuterol to BID Pulmicort Respules and prn Albuterol. NewFNP really felt like she empowered this mom to control her kid's asthma and got some buy-in about just how crucial this is. The mom was grateful and newFNP was invigorated.

NewFNP felt like it was one of the best FNP encounters she has had in such a long time.

Or maybe newFNP ate scrambled some Valium in her egg whites this morning and this lovely encounter (one of twenty-something) was all a glorious dream.

Don't be a fool - stay in school!

NewFNP loves school. She wishes that she could forever just go to school. The life of a student - a grad student that is - is one which suits newFNP to a T. Some classes, some studying/snacking/coffee at a local coffee house with her pals, some hitting the awesome 7-story gym provided to her by her educational institution, some thinking, contemplating, practicing, reading... you get the picture.

Now newFNP knows that high, middle and primary schools are not as much fun as grad school, yet they are probably more important because they are a platform, a springboard if you will, to bigger and better things.

Thus, newFNP's newest pet peeve: parents who are not teaching their kids to value school. It's always been an issue for newFNP, but this past week has been the worst. Take you kid to school, take their fucking TV out of their room if their grades are in the pooper and don't pull them out of school for 2 months to go visit relatives in another country. NewFNP just read an article in The New Yorker about parents pulling their kids out of an urban high school in Denver in order to take them to dry wall jobs. To newFNP, that is unconscionable.

Lest anyone think that newFNP was a child of privilege, let newFNP assure you that that is not the case. NewFNP's family simply taught newFNP's generation that we would be successful in education and life. The strategy worked.

NewFNP is not insensitive to the fact that people need to pay the rent. But here, in newFNP's frigging expensive city, if you don't want to live paycheck to paycheck, you had better get an education and a good job.

So go to frigging school!

And away you go!

NewFNP has noticed that it is, in fact, getting easier to know when to send patients to the ED. NewFNP has harbored a fear of over-reacting and sending patients to the ED when they are merely suffering from gas or a plateful of questionable seafood.

It's a fault of newFNP's training program, frankly - not enough experience with emergent patients.

Anywho, newFNP send yet another patient to the ED today. This lady weighed 350 pounds, had a smoking history of 35 pack years, sat for a multiple-hour car ride six days ago and has had exquisite left calf pain for 4 days. No relief with anything, worse with walking. NewFNP's clinic does not have the diagnostic equipment to rule out the DVT and newFNP's patient was at too high a risk to watch and wait. Was she short of breath? Hell yes she was, but who's to say whether it's from the magical combination of obesity and smoking or not? Her lungs sounded fine, but who can trust an auscultation through 2 inches of adipose? Did newFNP feel a cord, a pulsating mass, an area of increased warmth? She did not. However, this woman's calf had the circumference of a watermelon. NewFNP couldn't feel a thing.

Now, in general, newFNP hates to be wrong. However, newFNP hopes to be wrong about this patient. NewFNP hopes that she has some muscle spasm/arthritis/hypersensitivity - whatever. She just has to be sure. Yesterday, newFNP send a 16-week primip to the ED because she couldn't find a FHT after multiple attempts. Thankfully, the ED saw the heart beating on ultrasound. NewFNP is very thankful that she was wrong and doesn't want any patient to have a bad outcome to prove her right.

Vacation all newFNP ever wanted

NewFNP is counting down the days until her 2 week vacation. A little over a month and she will be jetting to a far away and exotic land - a land requiring both passport and visa, a land of monkeys and cows roaming the streets, a land requiring prophylactic Cipro.

But until then, newFNP continues to toil day in and day out. She dutifully educates regarding URI's and asthma. She skillfully performs paps as fast as possible. Just like a bank robbery - get in and get out. She supportively advises diabetic patients to lay off the orange soda, Hot Cheetos and multi-tortilla meals.

And today, she felt her first-ever silicone-injected buns. NewFNP's patient had visited another country for breast implants, rhinoplasty, Jolie lips and gluteal enhancement. If newFNP's readers have never felt silicone injected buns, they feel lumpy and hard. Perhaps newFNP's patient is the exception and perhaps silicone gluteal implants feel nice, but silicone injections do not. They especially do not feel nice when they are harboring a large, erythematous, taut abscess. But abscesses are old news to newFNP readers by now.

What is new to newFNP is the technique of packing the wound using a long q-tip to introduce the wick. For all these months, newFNP had been hoping and praying that her closed tweezers wouldn't accidentally open inside of her patients. Is it wrong to hope that newFNP will get to use her new technique soon?

And here's a little note to any male newFNP readers who might not have a clue. When someone like newFNP walks in the room and you give her a big hug, ask how she's doing and acknowledge that is has in fact been quite a while since you've had an appointment, the next thing out of your mouth should not be "Are you pregnant?" A good rule of thumb is that if there is a head sticking out of a woman's vagina, it's likely that she's pregnant. If it's 10-15 days after Channukah, Christmas, newFNP's birthday and new year's, it's a brilliant idea to cut a sister some slack and let the salads and gym kick in a bit.

Seriously, what the fuck?

Happy Holidays

NewFNP would like to institute a rule firmly stating that her schedule the week before Christmas and, equally as importantly, newFNP's birthday can accomodate only well visits and patients who would like to sit and chat about ways to keep healthy throughout this holiday season.

Patients who should bypass the tiny community health clinic and go straight to the emergency room include those who are a) new to the practice and b) 80 years old and c) having chest pain and dizziness and d) apparently carrying a right-sided heart the size of a Plymouth around in their chest as evidenced by ekg tracings. Shame on newFNP for forgetting to share that this gentleman also had inverted t-waves. At least the decision to send a chap like that to the ED is an easy one.

Similarly easy in the "A/P" department is a woman who is being seen for itchy eyes and has a blood pressure of 150/110 who casually notes that she has been snacking on ice for the past year or so and whose hemoglobin was an eye-popping 3.4. Note: blood should not be pink and watery. Merry Christmas and Happy Hanukkah - you're getting a blood transfusion! Hell, maybe even two!

As for newFNP, she has five consecutive days off and she frankly needs it. Burnout, baby, burnout. Five days should provide newFNP with a fresh outlook and, considering the season, perhaps some new fashions with which to create a vibrant return to the 'hood.

Heavy metal

Amongst many other ills one might see in an economically depressed community, newFNP's clinic sees a lot of children with elevated lead levels.

Now, when newFNP was in school, she was taught that it was the 18-month old child snacking on deliciously sweet paint chips off of brightly colored Mexican pottery or the child in an urban setting who lived next to a freeway/refinery/#2 pencil factory who was at risk for lead poisoning. In newFNP's clinic, we have another lead source: tamarind or 'chili' candies.

Now, newFNP is an unabashed sweet tooth, but she has never developed a taste for the chili candies. Little did she know that she was preventing herself from lead exposure. If she had developed this taste, she would be able to buy such candies by the bag-full from her local ice cream truck, the corner market or the streetside vendor. The lead is plentiful in newFNP's hood!

Getting these kids off the chili candies can be like getting Barry Bonds off the 'roids. According to the parents newFNP sees, it's the grandparents who are the tamarind-lead pushers. It's always those who you least expect!

newFNP writes for pleasure

Although newFNP has been in practice over a year, she is still surprised by the amount of firsts she has.

For instance, yesterday she was asked by a patient - in the hallway after the visit had ended - to write a letter on her behalf allowing her to bring her own linens to the conjugal visits with her incarcerated husband. Although she may have sensitive skin, newFNP's patient is clearly not a modest woman.

So let newFNP think. Hmm.... medical issue? She doesn't even have atopic dermatitis! Possible smuggling consequences? NewFNP is almost 100% sure that her malpractice insurance does not cover "prison break."

While considering her request, newFNP has tried to envision the sheets provided by the penal system for such purposes. Her hunch is that they are more 'army surplus blanket' than '600-thread count sateen'. All creature (dis)comforts aside, newFNP thinks that she will decline to write this utterly non-medical letter. Sadly, newFNP's patient will have to endure the prison-issue sheets and newFNP will have to deal with the resulting fungal, bacterial or viral consequences as they come.

On Call

NewFNP hates being on call for several very valid reasons.

One reason is that, for some reason, patients do not hesitate to call at 10:00 PM to cancel their dental appointment for the following day. After a glass of wine, newFNP could not give a shit whether or not you cancel your appointment and she most certainly does not want her private evening time disturbed by this mundane request. She also wonders who in the hell thinks to call the after-hours phone to cancel their appointment! NewFNP knows that many of her patients are not savvy and wishes that she was allowed to simply hang up on them. Alas, there is a record of who is on call and newFNP is still interested in maintaining her employment.

Secondly, newFNP has to cart the stupid call phone everywhere she goes, including the gym, dinners out, H&M, JCrew, etc. What the hell. Please, leave newFNP to her elliptical machine, hamachi carpaccio, $12 t-shirts and $150 cashmere v-necks in peace. NewFNP had 19 calls yesterday. Nineteen. One was for a medical reason. Eighteen were front office issues.

Finally, in newFNP's clinic, clinicians are not compensated for their on call time. If newFNP were compensated $5 per on-call day, she would have 3 new cashmere sweaters per annum. Now that would make the call experience much more worth it.

The three D's

NewFNP apologizes for the recent silence, but she has moved (homes, not clinics) and is just settling in to her new place. Ahhhh.... home sweet apartment home.

Anyway.

NewFNP must have previously noted how patients' chief complaints come in waves. One day it's nothing but pap smears - one vag after another. The only difference is the amount of hair. You might be surprised to know that a 250-pound woman has the flexibility to get a Brazilian but they do! The next day, one might be swimming in abscesses and chalazions. Frankly, it's uncanny - do newFNP's patients all know each other and coordinate their visits? Perhaps they figure that newFNP will really be on her game if they all come for the same thing on the same day. Suckers!

So newFNP just had the diabetes and depression day. Some patients even had both. Now, newFNP is no expert on either, but can manage each effectively in the primary care setting. NewFNP admits that she is a little dodgy when it comes to changing for oral hypoglycemics to insulin, but she has no fear regarding starting an adult patient with depression on an SSRI. But one after the frigging other for eight hours? Fucking hell. NewFNP thinks of her mental health colleagues and is so thankful that there are people in this world who can address these sometimes debilitating depression cases. Because newFNP sure as hell cannot during her 15 minutes. The diabetes/depression day is not a rewarding one for newFNP. It just doesn't make for a fun clinic day.

That is until newFNP was rewarded for her diabetes/depression diligence with The Third D: Dookie. Now, newFNP is no stranger to euphemisms for the act of moving one's bowels. She generally, however, reserves 'dookie' for elementary school students and not for 38-year old men. NewFNP truly attempts to be professional during her visits with patients, but then someone says something like this, "Yeah, I used to dookie like 3 or 4 times a day, but now I maybe dook once. Maybe twice, but I used to dookie a lot." All that newFNP heard was "dookie, dook, dook, dookie, dook." Oh, it was awesome. NewFNP was biting the inside of her lip in order not to start laughing.

The Dook. NewFNP will never forget him.

Get out the vote

NewFNP's clinic had a little excitement today.

No, newFNP is not speaking of the large anal warts she saw, nor of the 29-pound 13 month old whose parents state that they give her about 80 ounces of whole milk per day, in addition to both chocolate milk, juice and the occasional soda.

Nope, newFNP's clinic had a visit from our state's democratic gubernatorial candidate. In what newFNP considers a 'preaching to the choir' get out the vote effort, Mr. Candidate did a little walk through, hand-shaking, baby-kissing visit complete with secret service and television cameras. NewFNP has already voted for this underdog thanks to the ole absentee ballot, but she was glad to see him seeing a side of our city that many politicians would love to - and largely do - ignore.

Thank goodness newFNP was still rocking the sleek blowout from her star hairdresser and was wearing a smart outfit today!

MRSA! MRSA! MRSA!

NewFNP has had some tough patients this week.

There was the 80-year old with CHF and hepatic congestion. Do they make liver sudafed because we need to decongest that bad boy!? NewFNP is decongesting that old liver and treating the CHF with good old-fashioned furosemide, which should really improve her urinary incontinence. Sorry about that.

Then there was the lady who was adamant that newFNP had not refilled her Relpax last month. NewFNP remembers the conversation in which she said that she would refill it. NewFNP wrote in the chart that she refilled it, but did newFNP hand the medicine to the patient herself? No, she did not. That responsibility falls to our dispensary clerk, who is sweet yet lacks a certain something - let's call it IQ/ability to multi-task/grace under pressure. It is not out of the realm of possibility to think that newFNP's patient perhaps did not receive her medications. However, newFNP has to trust herself and her employees and, thus, did not refill the med. NewFNP's patient was practically homicidal. It was not an enjoyable experience. Yes, newFNP knows that you are not stupid. Of course, newFNP appreciates that you are not a liar. Yes, newFNP understands that you would like her to supervise every interaction that occurs between all staff members and patients of the clinic. Sadly, newFNP has 29 other patients to see. NewFNP apologized, of course, but our relationship is damaged.

NewFNP hasn't had too many patients get mad at her. It was a drag, but newFNP had to stick by her staff because there was no clear mistake. The documentation stated that the patient received the medication. Bummer.

In other news, apparently the power of the blog is beyond what newFNP imagined. After posting that she hadn't heard from clinic B, newFNP received an e-mail asking her to interview... this Thursday at 9AM. This e-mail came in one week after newFNP's e-mail went out. How about some advanced notice for schedule clearing purposes? We'll see. We'll see.

And finally, check out this article on slate.com about antibiotic resistance.
http://www.slate.com/id/2152118/
Not a day goes by during which newFNP does not chastise a patient about antibiotic misuse. Come on people! Get with the program!

Was it something I said?

NewFNP feels like a rejected internet dater.

After being sought out via e-mail to interview at community health clinic B, newFNP replied to said clinic's Assistant Medical Director using the same medium, stating that she would love to interview, knows of the great work clinic B does, etc, etc.

That was a week ago. Nothing. Is newFNP P.N.G. at clinic B without even knowing it?

Oh well. NewFNP hears that community health clinic B pays shit, so that wouldn't work anyway. Since graduating, newFNP has noticed that many of her conversations with her late 20's/early 30-something friends focus on paying off debt, saving for a down payment, paying off private loans super-ASAP, how the fuck anyone ever buys a house, etc. Therefore, newFNP certainly cannot earn less than what she now earns. Seriously, newFNP still drives the same piece of dump she drove in grad school and rents an apartment.

So screw you clinic B! NewFNP will make the most of clinic A for now. At least she has some good stories to share.

What to do, what to do

As many of you know, newFNP has been experiencing distress at her place of employment as of late. This distress led newFNP to forward her CV to two of her public health type colleagues who are, as they say, connected.

And now newFNP has a job interview at the Cadillac of community health clinics.

Here is the conundrum. There is never a *good* time to change jobs. There are times that are worse than others. For example, newFNP has a three-week vacation planned in February. Is it a bad thing to say, "Oh, and BTW, I'm going to need to take February off. Problem with that?" NewFNP thinks that is not ideal. Secondly, newFNP let her CPR certification lapse. Fucking hell because now newFNP has to sit in that MF-ing course all over again. Double fucking hell because it looks flat out bad to let such a thing lapse when applying for new employment. Thirdly, newFNP's clinic just lost a provider - no big shock. This does, however, cause extra stress on the existing staff.

Finally, newFNP really likes and respects the MD with whom she works. NewFNP will need to excuse herself from work for a half-day to attend said interview. NewFNP wants to tell her MD, but doesn't want her MD to think she is a big ship-jumping a-hole. Ay ay ay. And newFNP is not even sure that she wants to leave her fucked up community health clinic for a more posh community health clinic. This posh clinic is at least 15 minutes further from newFNP's new apartment and, in newFNP's city, that could be a real problem.

NewFNP has about 10.5 hours to figure this all out.

Hard times are spreading...

Oh, has it ever been rough in newFNP land. NewFNP has had nothing good to say about work. No funny stories, no frustrating patients. Wait, did newFNP just write that? Of course there have been frustrating patients! But newFNP has been too discouraged to share them with anyone.

You see, newFNP's Board of Director's voted down all of the clinic employee raises. NewFNP's clinic manager continues to jam the clinic with too many patients. NewFNP had a size large bloody speculum fly out of a vagina at her yesterday (lesson: no matter what - hold onto the speculum). Oh, the velocity!

In short, newFNP feel overwhelmed and underappreciated. Maybe newFNP has too many entitlement issues. Maybe she should look at her job as just that - a job.

But that is *not* how newFNP sees her role. NewFNP is not a telemarketer. She has chosen a career that values humanity and that seeks to promote wellness. NewFNP wants the agency for whom she works to value her in kind.

And newFNP can't stress it enough, but she needs cute shoes and some new Joe's Jeans!

Stay away from the windows

It has been an exciting few days in newFNP land.

In addition to the minimum 27 patients per day newFNP has seen this past week (range 27-34), we had a little drive-by shooting fatality/car crash in a too-close-for-comfort location. And by that, newFNP does mean visible from the front door of the clinic. NewFNP was all for closing up shop that day but alas - once the fun and games of clearing away the body and the cars was taken care of, all returned to normal. Only the disconcerting knowledge that newFNP does, in fact, work in the hoodiest of hoods remains.

Thankfully, newFNP had an unexpected treat today. As she deftly moved around her patient to partake of a thorough lung exam, she was treated with a rare sight: a mullet. A wavy mullet. Others might not find joy in the mullet, but newFNP was thrilled! It's not so often that anyone rocks the Billy Ray Cyrus these days!

It was a high in newFNP's achy breaky day.

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.