Take that, newFNP!

NewFNP's clinic so rarely prescribes scheduled drugs that newFNP always feels a little hesitant to write for them.  Of course, there are exceptions to this, but these exceptions tend to occur in established patients with acute pain or anxiety or what-have-you.

They do not tend to occur with new walk-in patients who are at their third clinic in six months, who slur their speech and who disclose that they have been on SSI and have never worked due to asthma and back pain and knee pain and arthritis.  And who need Trazadone and Lorazepam to sleep every night.

Now, newFNP is sympathetic to the fact that people have and need treatment for pain and anxiety.  NewFNP is aware that people who are dependent on narcotics often need more narcotics to control their pain.  But newFNP's clinic is a) not a pain management clinic and b) situated in a crappy neighborhood with enough of a drug problem.  

And this patient was, frankly, just full of red flags.

So newFNP decided that she would refill this patient's lorazepam - it's not oxycontin after all - but that she would only give her 10 tablets while she awaited the medical records from her former provider.  Ditto the Trazadone.

Fucking hell, did the encounter ever go to the dogs!  NewFNP, apparently, had offended this patient by telling her that she needed to see her voluminous medical record before being able to continue her medical excuse for SSI and that 10 lorazepam was unacceptably stingy.  She was quite clear in her dissatisfaction.  Her exact words to newFNP were, "I need 10 lorazepams just to deal with people like you!"  It was a refreshingly honest statement.  She then informed newFNP that she will be no longer seeking care at newFNP's urban community health clinic, or more specifically and pointedly, with newFNP.

NewFNP breathed  sigh of relief. 

NewFNP probably could have handled this encounter better, but so could have newFNP's patient.  Like, for instance, slurring during the encounter generally does not bode well when one is seeking anxiolytics ad libitum.  

In retrospect, newFNP is sure that she had judgment in her voice when she told her patient about not freely authorizing SSI and med refills.  She feels badly about this and, with the next patient, she will choose her words more carefully.  But perhaps this woman has been screwing over the system.  NewFNP doesn't know and this patient just didn't seem to warrant the benefit of the doubt today.  

Feeling uncomfortable with the secure prescription pad in hand is not a sensation newFNP likes to experience.  Would newFNP have killed this woman if she write her for 20 or 30 lorazepam?  Doubtful.  Would the encounter have been more pleasant for the both of us?  Certainly.  

But newFNP had to do what she felt was right.  

Light and bright day

NewFNP returned from a quick yet lovely weekend trip to a nearby vacation island and was welcomed back to the clinic with a gloriously light day.  Eighteen patients, two of whom were 'productivity boosters', a phrase newFNP has coined to describe patients for whom one signs a superbill yet who require minimal care, such as vaccine visits or family planning counseling visits.

The beauty of the light clinic day is that when a woman presents for her pap and casually mentions that she would like an IUD, newFNP offers to do it all at the same time.  And voila!  Five years of protection and a pap result on the way.  Or when a patient happens to note that it has been three years since her last pap, newFNP does not feel a twinge of regret as she offers to do the pap right then and there and the patient accepts.  

During a light clinical day, newFNP also has time to create an ongoing health maintenance flow sheet, something our charts lack and that has been bemoaned aplenty lately in staff meetings.  Just give newFNP 10 minutes and she'll whip it up!  Give her another 10 minutes and she'll research locums and on-call answering services!  Hell, give newFNP an hour and she'll re-create every fucking form that sucks in the charts.  Rocket science though these activities may not be, they are important in daily clinical life.

NewFNP also had an opportunity to continue her conversation with the doctor who so offended her the other day.  Taking a chance, newFNP told her that she really had felt upset that it seemed that the doctor thought her voice was less important because she is an NP rather than an MD.  NewFNP does believe this woman when she says that was not her intention.  It calls to mind the importance how we use language and being mindful of other people.  NewFNP is so incredibly guilty of intermittent foot-in-mouth disease.  But it also made newFNP realize how important it is for her to a) feel like she is an important part of this team, motley though it may be and b) to feel empowered to speak out when she feels belittled or devalued.

If newFNP has a post-vernal equinox prayer, it is to continue with light clinic days.  And to have J. Crew cashmere go on sale.  And to have student loan debt bailout by JP Morgan Chase.  Come on!  Bail a hard-workin' sister out!

Follow up

NewFNP just received an apology e-mail from the offending doctor.  

Now newFNP feels a little guilty, but feelings are feelings and newFNP felt offended.  NewFNP may take this opportunity to do a little education about language and what may be construed as hurtful.  However, the apology does engender some goodwill in newFNP's heart.

Um, excuse me, but screw you.

Oh, how the tide changes from one day to the next.  Yesterday, newFNP was busy as hell, yet she didn't feel as though she had been crushed by a wooly mammoth when she returned home. In fact, as readers may recall, she actually felt wonderful.

Today, not so much.

Yes, it was busy.  That is the only similarity.  Busy, busy, busy with uncontrolled diabetics, physicals and a slough of other utterly non-interesting cases.  And busy with an infuriatingly frustrating all-staff meeting-slash-clusterfuck at the end of the day.  

It started out innocently enough.  Introductions, welcome new staff, blah blah blah.  Then newFNP's CEO moved on to the very touchy subject of providing decent care.  

In newFNP's clinic, there is no such thing as patient flow.  We do not have EMR; there are no reminder cards that it is time for your pap or mammogram or cholesterol screening.  Patients come in waves - charts overwhelm the hard plastic bins in which they are placed while providers attempt to make it through visits.  There is no urgent care clinic, nor are there hours set aside for urgent care.  Walk-ins are folded into the schedule along with appointed patients. Sometimes appointments are cancelled when the front-desk floodgate is so widely opened that the walk-in deluge overwhelms capacity.  Some providers see the expected amount of patients - about 25 per day.  Others see far fewer.

These are a few of the issues in newFNP's clinic.  Is it any wonder that we miss screening tests, the topic that opened this Pandora's Box? Theoretically, all it takes for a provider to miss something is too little time or too little motivation.  At times, newFNP is sure that even the best provider has been overworked or lazy or distracted.

So what does newFNP's clinic want?  Do they want thorough care or do they want fast care?  Do they want urgent care or do they want primary care?  Because they just cannot have both in the "system" currently in place.  

And then to top it off, newFNP had her first real taste of subtle NP-bashing while chatting about these issues with three of the physicians and the CEO after the meeting.

"Really," the new doctor said, "I'm the only doctor in C. [her clinical site in a nearby neighborhood]." Directing her eyes toward the two other physicians, she continued, "I think we should get together and talk about these issues."  

"Get together as doctors or get together as providers?" newFNP asked.  

"As providers, if mid-levels are interested.  I just don't see a lot of mid-level interest in these systems issues in C.," she responded.  

Yeah, asshole, mid-levels are interested.  NewFNP has been quite vocal about this for the past two and a half years.  She has met with the CEO.  She has talked to the CMO. She has discussed ideas with other providers.  She brings up systems issues in every provider meeting.  But unless management gets on board with these changes, newFNP may as well just spend her energy window shopping as Barneys because she is just as likely to have a closetful of Manolos and Marc Jacobs as she is to have these changes come to fruition. 

What is more maddening is that, up until this comment, newFNP always felt like she had a respected voice in this discussion.  It is fucking bad enough that the expectations for productivity are so high and that newFNP's patient flow is relentless.  But then to be devalued by a provider who has been working part-time at the clinic for all of three months?  NewFNP knows that there are physicians who just think that NPs and PAs are idiots, but aren't they smart enough to simply wait until the NP or PA leaves before they insult them?  And if you think that NPs and PAs are lame, why in the fuck would you work in community health where there are tons of them!

Unacceptable.

Healing.

It would have been easy for newFNP to just blow off the attitude of the almost thirteen-year old obese boy who begrudgingly attended his well child visit with his mom today.  Eyes steadfastly examining a single spot in the floor, his 213-pound frame turned away from his mom and from newFNP, he initially refused to respond to newFNP's questions or to his mom's exasperated pleas for the responses.

"You see, Doctora?" she lamented.  "This is how he always is."

NewFNP cares for this boy, his two younger brothers, his mom - who has diabetes - and his grandma who also has diabetes and who has had two strokes.  His mom cares for herself, her mother and her four children as best she can.  One older boy is on house arrest.  As newFNP flipped back to the last physical, she saw in her handwriting: father incarcerated.

NewFNP knew that this attitude was about that.  She asked the patient if his dad was still in jail - he is.  She asked him if that was why he was upset.  It was.  She asked the patient's mom to leave them alone, not quite certain how to broach the subject of the kid's attitude and his father's incarceration.  These topics are difficult for newFNP - she often feel like the emotional equivalent of a bull in a china shop when she has to discuss them.

True to that expectation, newFNP's start was rocky.  She asked her patient, whose emotional pain was weighing heavily in the room, to please look at her.  He refused.  She told him that it would mean a lot to her if he could just look at her.  He made a micro-movement toward her, decided against it and again faced the floor and told her no.  

NewFNP said, and in writing this she knows that it is harsh, "OK, so you just want to sit here and be a jerk?"  He said yes.  This affirmation opened the door for newFNP to ask him who has told him that he is a jerk.  

And the floodgates opened.  NewFNP is not sure what she would have done if they had not but it doesn't take a psychic to know that this kid has had a lot of negativity directed towards him.  'Jerk' may have been tame compared to other names he has been called. 

NewFNP spent the next twenty minutes listening to this devastated kid cry about how he misses his dad.  It was absolutely heartbreaking.  He doesn't want to go to school because his dad used to take him.  He doesn't want to go to the park because he sees all the other kids with their dads.  When someone picks on him at home, no one is there to defend him like his dad used to.  He is about to turn thirteen and all he wants for his birthday is to visit his father in prison.  He is concerned that he will be deported and that he won't see him again.  His uncle is mean to him, tells him bad words and to "calm the fuck down."  His aunt yells at him.  His mom is frustrated with him.

NewFNP was, frankly, not sure what to do.  Obviously, this kid is at high risk for school failure, perhaps for criminal behavior given that his brother and father both modeled it for him.  NewFNP knows that he is also at high risk for diabetes, that he already has fatty liver infiltration and she assumes that part of this overeating has an emotional component.  She made an executive decision to blow off the medical concerns for today - at least in part - and to focus more on his emotional decompensation.

She told him that he has already seen too much and suffered too much for his young life, acknowledged that life has dealt him an unfair hand, allowed him to grieve his loss and his loneliness.  She talked to him about his potential, about making good decisions and about how he is loved.  She told him that she saw a sweet person inside who wanted love and caretaking.  

She just let him cry and tell his story as, in the world according to newFNP, telling one's story is an important therapeutic process.  

At the end of the visit, newFNP listened to the kid's heart.  She let him listen to it - it was the first time he smiled during the visit.  She asked his permission to check his blood and ordered a cholesterol, a comprehensive metabolic panel and an A1c - just in case.  She told him that she would see him in two weeks.  The nutritionist referral will have to wait until then.

NewFNP left him in the room and spent a few minutes with his mom.  She asked her to tell him every day that she loved him.  She asked him to tell her bullying brother to lay the fuck off.  She told his mom that she was very worried about this sensitive and hurting boy.

NewFNP was e-mailing a pal from public health school to ask about mentoring programs for this kid when she heard him call her name.  She turned around and he gave her a big hug and thanked her.  

Even though newFNP thought how she was utterly powerless to change this kid's life during her encounter with him today, she simultaneously felt so grateful for the opportunity to say kind words to a troubled adolescent.  She needed that.  Clinic has been so overwhelmingly thankless lately that she had been questioning whether or not she could stay.  

Even though newFNP didn't do much medicine with this guy, she definitely did some nursing.  And some social work.  And it felt really, really good.

Mama mia!

Yesterday afternoon, as newFNP looked at the pregnant seventh grader sitting across the room from her, she searched her eyes for a glint of fear, of recognition of the gravity of her gravid situation, and for a seed of doubt that would allow newFNP to introduce the topics of abortion or adoption.  She struck out.  She brought them up anyway.

Perhaps it was because this young woman appeared to have the IQ of a toadstool.  Perhaps it is because her sister is twenty-one and has five, yes five, children.  Perhaps it is because her dad was deported a few years ago or because her brother recently died.  Perhaps the ole 1-2-3-4 punch - shitty life circumstances leading to seeking love and affection in the arms and bed of a horny fifteen-year old boy, infinitely desirable in his scowl, his Nightmare Before Christmas hoodie and his Vans slip-ons.

Whatever the reasons, this just-turned-fourteen-year old girl was convinced that motherhood was the best option for her.  OK.  NewFNP took a deep breath, attempted to put her judgements aside and started talking more about self-care, about breastfeeding, about finishing middle school and then high school, about bringing her frigging mother to her next prenatal appointment.

  

NewFNP auscultated fetal heart tones, reviewed lab results, talked a little about fetal development and the importance of nutrition and then exited the exam room to have a shit fit and find the prenatal care coordinator who would hook this very young lady up with prenatal case management, parenting classes and God knows whatever else a fourteen-year old needs in order to become the best parent she can be.  

NewFNP's prenatal care coordinator, PCC, is lovely.  She is twenty-four and she also got pregnant for the first time when she was thirteen.  As she tells it, her Pentecostal preacher father was none too pleased.  She delivered her now ten-year old son at the age of fourteen and her daughter at the age of eighteen.  Despite many bumps in the road with her children's father, they remain married and, as far as newFNP knows, happy.  She started out several years ago as an MA in newFNP's clinic.  Because she is personable and talented, as well as smart, she was promoted to the position of prenatal care coordinator and has done remarkably well with the new responsibilities.  

NewFNP's patient is no PCC.  NewFNP is concerned the PCC is the exception and newFNP's patient is the rule.  Nevertheless, newFNP will continue to support her in having a healthy pregnancy and baby and, if she decides that adoption is a good plan after all, newFNP will be there with the referrals.

As an aside, since when are fourteen-year olds in seventh grade?  NewFNP was a sophomore year in high school when she was fourteen.  Aren't we at least supposed to be in ninth grade?

A little rash

NewFNP walked into clinic Tuesday - a different site from where she usually works - and her MA asked her to please take a gander at the little girl in room 3 with a rash.  

A rash??  Holy shit, and how!

This little girl's skin was fucking polka-dotted.  Ears, face, trunk, legs, arms, neck and -- hey there --palms and soles.  Did newFNP mention that this four-year old's temp was 103?  And that two of the lesions seemed purpuric.  And that she showed increased work of breathing?  And that she had conjuctivitis?  And coryza?

Inside, newFNP was like this: Shit!! What the fuck?  Help!  Inside, newFNP asked the mom about medications.  None.  Known allergies?  None.  Travel history?  None.  Pain?  None.  Vaccines?  No four-year old vaccines yet, but the girl was only two weeks past her fourth birthday.  Otherwise, up to date.  Onset? About twelve hours prior, as a single lesion on her arm.  Scared?  Yes.  The patient and newFNP.

NewFNP must admit that her differentials included holy shit, what the fuck is this? and who fucking knows but she's going to the ED.  NewFNP tried to calm herself down and think of what causes palmar rashes.  Syphilis.  Allergy.  Help!

NewFNP ruled out syphilis because, high risk though her clinic may be, no -- just no.  And her history didn't lend itself to the diagnosis of allergic reaction.

At this point, newFNP knew that she was dealing with a case requiring consultation.  She called Dr. Dual-Ivy-League-Degrees who raised the concern for meningitis and supported newFNP's decision to send the girl to the ED.  

The patient's mom offered to take the little girl on the bus.  Gold star for flexibility, not so much for public health.  NewFNP arranged alternative transportation and affixed a surgical mask to the girl's face in the off-chance that the rash was, in fact, meningeal.

NewFNP called the parents last night.  The little girl was being discharged after having been observed for twenty-four hours for suspicion of the very freaky Stevens-Johnson syndrome.  Apparently, she must not have had it or she wouldn't have been discharged, right?  NewFNP is dying to read the hospital notes.  

The ER docs attributed her reaction to a Motrin allergy.  Now, newFNP did not get this information in clinic and actually gave the patient a whopping dose of Motrin to bring that fever down.  Frankly, newFNP is suspicious of this diagnosis.  Sure, she won't give Motrin to this patient in the future, but a temp of 103?!?  Perhaps that is a confounder in this case.

Man, is newFNP ever lucky that this girl was her first patient of the day and not her last!  

Yo bro

If there is one thing to which newFNP is sensitive, it is to the discussion of acne. 

NewFNP has frequently professed her love of Retin-A, but prior to extolling its virtues, newFNP was a begrudging fan of its stronger, more teratogenic cousin: Accutane.  NewFNP's skin was not always so clear and lovely and newFNP felt quite unattractive as a result.  By the time she got hooked on the Accutane, she had tried what seemed like trillions of topical and oral antibiotics, all to no avail.  NewFNP was, by that time, very sensitive about her skin.

Therefore, when newFNP has a patient with acne, she broaches the subject gently.  She may say something like, "NewFNP sees that you've been breaking out a little bit.  Would you like her to write you a prescription to help with that?"  This is perhaps the only circumstance in her life in which newFNP has never been refused.  Patients generally want help and are thankful when the offer is extended.

NewFNP had a teenage patient in clinic for a non-derm related complaint last week. He sat on the exam table, his mom and 7-year old brother on the chairs.  NewFNP addressed his complaint and then turned the topic to that of acne, which she acknowledged as being a normal and treatable adolescent process.  Following the rule, newFNP's patient and his mom were grateful for the offer of help.

His brother, however, had another response.

"Pimples!!!" he yelled out with glee.  

Ah, brothers.  You've gotta love 'em.

Yowza!

School avoidance is a universal phenomenon.   Say, for instance, you are a student at a very fancy, very name-brand nursing school and you are about to graduate and you have a horrible coma-inducing class from 5-7 PM on Thursdays.  That situation is a perfect set-up for school avoidance!!  Not that newFNP ever found herself in such a situation - she's just sayin!

Another universal phenomenon is that pre-adolescents and adolescents are embarrassed by their parents.  One day, Madonna's kids will be embarrassed by her.  Brangelina's kids will lament their misfortune at having such uncool parents.  George Clooney may possibly escape this phenomenon, but as far as newFNP knows, he is sans progeny, so we will never know.

Well, one thing that might make a kid want to avoid school is if kids in your 7th grade class made fun of your mom.  And one thing that might make kids make fun of your mom is if she showed up to pick you up, was overweight, yet wearing a leopard print halter top showcasing striated bosoms, white denim Daisy Dukes and had an unfortunate home experiment with bleach technology - 4 to 6 weeks ago if newFNP correctly noted the root growth - thus rendering her hair a Tony the Tiger shade of orange.

NewFNP remembers feeling horrified that her mom had the lamest jeans.  And they were full length and she probably had a regular sweater or lady-blouse and some sweet baby-blue high-top Reeboks circa 1985 and had respectable highlights.  NewFNP's mom was known as a cool mom and newFNP still felt embarrassed by her.  

This poor little guy must have felt really bummed - newFNP can only imagine what those sharp-tongued little 13-year olds said to her patient.  

But what it is about a parent that makes her not intuitively get that dressing like a Kit Kat Club dancer is no way to roll when you're picking the kids up from school?  Or ever!  Just throw on some sweat pants and a smart cardigan before you roll up on the middle school, for Pete's sake.

Introspection

NewFNP has recently begun to wonder more and more -- is she part of the solution or part of the problem?

NewFNP is type A to the nth degree, she is a stubborn Capricorn and she is addicted to having things done correctly, generally on the first try.  She is unfailingly punctual.  She expects that the people with whom she works will get their jobs done correctly so that her job is easier.   

Perhaps these personality traits are more suited to, oh let's say, dictator than to that of an FNP in a community health clinic.  While newFNP knows that her expectations oftentimes exceed the ability of her support staff and sometimes of other clinical staff, during a busy clinical day in which newFNP is correcting the mistakes or oversights or laziness of others, she cannot help but to grow frustrated.

NewFNP is so used to having things screwed up that she perpetually dreads and anticipates the mistake du jour.  

For instance, last Friday, three providers were scheduled, two were working and zero patients were cancelled until newFNP had a fit of apoplecty in front of the clinic manager and scheduler.* Today, one of newFNP's clinical colleagues left early and newFNP was overly sensitive to ensuring that the front desk staff was aware of her departure and would allow for a reduction in patients as a result of having one less provider.  NewFNP is so sensitive to foolishly booked schedules that she was unable to see her way through the management of two physicals scheduled at the same time - mom and baby - who arrived an hour late and wanted to be seen together.  Though not an unreasonable request, it seems more unreasonable when A) the one month old boy's father was present and B) the pair were an hour late.

NewFNP is confused.  She has autonomy in her practice, the physicians do not see her as incompetent or "less than" because she chose to be a nurse rather than a doctor, she has decent benefits and a reasonable salary, although that last point is negotiable.  

But is newFNP doing any good when she feels like she is walking into the DMZ as she crosses her clinic's threshold?  Do other providers have to remind themselves to smile?  Is her frustration causing her circulating cortisol level to rise to the point where newFNP will be rendered infertile and laden with belly fat?  Will she need therapy, IVF and relacore?

Is it worth it?  Is this just what it is, what it always will be?

In writing this, newFNP thinks back to this morning when she arrived at her desk to find a sweet coffee cup, wrapped in paper towel - a gift from a patient.  So lovely and sweet.  Is newFNP an asshole for thinking of leaving these sweet patients, frustrating though they and the practice may be?  

NewFNP is holding out for the four-day workweek.  Rumors have been circulating that the clinics may open for extended hours.  Three days off each week might be the ticket.  Hiking, movies, yoga, hair-dos, shopping, cooking.  That may just turn over a new, happy leaf in newFNP. 

* Alas, not the first time.

Thanks, buddy.

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

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

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

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

If she wanted??

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

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

Oink

Gone are newFNP's mojitos and walks along the malecon.  She is now back in the thick of it but very thrilled to have a new referral source to help out her patients.

NewFNP's clinic is very lucky to have our nutritionist, Red.  She is not to be confused with the pirate nutritionist, who must be swashbuckling with some bonny lasses as she has been nowhere to be seen.  No, Red has been a presence three days a week and thankfully so!

NewFNP had a sweet patient this week who wants to get pregnant.  Super!  Only it's not so super that she is over 350 pounds and has her periods 2-3 times per year.  NewFNP did some general education, gave her some folic acid and sent her to Red for a more thorough intervention.

Later, newFNP perused Red's note to see what, in fact, nutritionists talk about in their sessions, where they chart, etc.  What newFNP found was astonishing!

Those in the know are familiar with the SOAP note that providers use to describe the clinic visit: subjective history and complaint, objective findings, assessment and plan.  Learn it, live it, love it.  

Well, nutritionists apparently have their own format.  It goes a little something like this: problem, intervention, goal.  

PIG.  

The frigging nutritionists use PIG!  What the fuck?  That is so wrong.  So, so wrong.  Has no nutritionist ever stopped to think of the cruel irony?

PIG.  Seriously people, what the fuck.

Shit.

When newFNP last wrote, she noted that she had disclosed to a patient that she was HIV-positive.  NewFNP was wrong.  

She has AIDS.  

When newFNP told her patient that she was HIV-positive, her patient asked, "Does that mean I have AIDS?"  When she asked, newFNP knew that AIDS was a possibility.  NewFNP replied that she would know more when she got the rest of the blood-work back.

Her CD4 count came back today at 166 - an AIDS defining number according to the 1993 AIDS Surveillance Case Definition of the CDC.  NewFNP had a shit fit when she learned from the lab that the viral load was submitted incorrectly and could not be determined.  It matters and it doesn't.  The CD4 count is in the toilet, the patient is smoking crack and drinking on a daily basis and newFNP can't reach her.  She can't start on anti-retrovirals anyway - you don't want to have a patient fail her first, and best, option and - frankly - active debilitating addiction is not an ideal starting place for HAART if one is looking to prevent resistance.  

The situation is, pardon newFNP's French, fucked.

NewFNP wrote the prescription for Bactrim for PCP prophylaxis and attempted to reach her patient in order to get it started.  Of course, being precariously housed and without a phone, newFNP could only leave a non-specific message on her patient's friend's cell phone.

NewFNP's patient did not show up in clinic today to pick up the prescription.

NewFNP's passport is out and her dollars are exchanged as she is heading out for a longer long weekend in a far-away land.  But newFNP's patient will weigh heavily on her heart while she is away.

So, so sad.

End of the day blues

At the end of the day, newFNP likes the following types of patients: medication refills; normal lab results; well-child visits with vaccines already up to date; hell, even an uncomplicated UTI is fine!

But a blood pressure of 190/110 in room 4 and an as-of-yet undisclosed HIV-positive drug addict/alcoholic in room 5?  At 4:30?  Unacceptable.

Unacceptable and sad.

Again, newFNP will counsel that resisting the lure of daily crack and malt liquor use, coupled with exchanging sex for money and drugs, is a step in the right direction if one is interested in preserving one's health.  

But, even though newFNP's patient knew that she had engaged in some risky behaviors in the past, that did not make it any easier for her to hear the news.  This 6-foot tall, 130-pound woman who smelled strongly of booze sobbed, her face in her hands and her skinny body slumped on the uncomfortable plastic seat in the exam room.  

"Is that why I can't gain no weight?" she asked newFNP.  Could be.  But maybe the daily crack use has something to do with that as well.  Just a thought.

NewFNP frequently uses "we" when she is discussing sub-ideal behaviors with her patients, a la, "Sometimes when we are emotionally distressed, we gorge on mango Mochi" or "Sometimes we over-do it on shrimp dip during the holidays."  Nonetheless, when her patient asked why this was happening to her, newFNP was somewhat surprised to hear herself say, "Sometimes when we have a serious addiction, we trade sex for drugs or money and don't use condoms."  That elicited a nod of agreement from her patient and, truthfully, a little internal chuckle in newFNP.  Yeah, survival sex has played such a big role in newFNP's life.    

NewFNP did her patient's exam: lungs clear, heart regular, nodes everywhere, pap pending.  She drew lab work: CD4, viral load, RPR, heps AB&C, toxoplasmosis IgG, CMV IgG.  She gave her referrals to HIV clinics.  She encouraged her to attempt sobriety.  

It was a tough encounter for newFNP.  She wanted to handle this one right, to be a voice of support and caring in the life of a woman who has clearly lacked these two things in the past.  NewFNP thinks that she achieved that, but it is kind of hard to tell when your patient is drunk, probably has some underlying mental illness and is devastated.

Oh, and newFNP got the other patient's BP down to a marginal 146/95 and sent him on his way with three BP meds and a follow-up appointment.  It sucks to have to have given pretty decent care to one patient to the detriment of the other patient.  Both patients have potentially deadly conditions, both are rather poor at compliance, but only one got a full 45 minutes of newFNP's time.  

Take a tip

NewFNP is not going to sit here and tell you that she doesn't love herself a little Q-Tip action every once in a while.  It feels good.  And newFNP is not referring to an external cleaning, folks.  Au contraire, she is referring to the glorious sensation experienced with the insertion and rotation of the Q-Tip into the forbidden zone of the ear canal.

Mmmmmm......

But, people, please.  Once a week.  Twice if you are a true Q-Tip addict.  Do not push your billions of pounds of wet wax up against your TM.  

Because the amount of hard, brown wax - often replete with hair or other debris - which newFNP has been lavaging from canal after canal lately is getting overwhelming.  It is feasible, although as of yet unproven, that newFNP may have helped someone achieve a normal BMI through nothing more than a vigorous ear-cleaning.

When newFNP has a chief complaint of otalgia for three weeks, with or without decreased hearing, cerumenosis in atop her list of differentials.  And newFNP is a skilled clog-buster!  

When newFNP counsels patients to lay off the tips to prevent future cerumen log-jams, she frequently hears the lament that ears itch.  NewFNP knows that ears itch.  But guess what, dear patient?  Stripping them of every drop of wax will only worsen the pruritis!

When newFNP shares this fun fact with patients, she frequently receives a look that she has grown to know as the "you're fucking crazy and now I can believe nothing you say" facial expression.  She receives the same look when she says that, for optimal health, one need not eat red meat three times daily and again when she counsels that Gatorade is, in fact, not healthful when consumed in copious amounts.  

Water, friends, water.  Dilute it with hydrogen peroxide for the ears and straight from the tap/bottle/trickling mountain stream for the body.

Bonus info: In addition to being related to such conditions as polycystic kidney disease (gene PKD1) and tuberous sclerosis (gene TSC2), chromosome 16 is responsible for determining what type of cerumen you have - dry or wet.

D.A.R.E.

NewFNP has one word of advice for readers out there who may be considering dabbling in methamphetamine use: don't.

Please, just have some Two Buck Chuck or treat yourself right and share a $20 bottle of Pinot Noir with your special pal, but for the love of Pete, stay off the meth.

It's not like the skin-picking is bad enough.  Sure, it's awful to be paranoid and feel certain that there are bugs under your skin.  That's no good dirty poop!

But then you get the tooth rot, the horrible tooth rot and that is truly awful on several levels. 

For one, anyone who has ever heard of methamphetamine has probably heard of "meth mouth."  So not only do you have a frightful looking mouth, tons of people will know why your teeth are decayed brown stubs.

For two, it's hard to find a job if your mouth if full of rot, even if you have been clean for years.

For three, you feel self-conscious about your appearance and don't want to smile.

For four, you can't chew and, if you try, it hurts.  And you risk worsening infection.

And finally, when you are getting your dental clearance from newFNP, you can pull pieces of your rotting teeth out of your mouth for show and tell.  As if newFNP didn't believe that a mouth full of stubby brown and black nubs and one solitary whitish partial tooth warranted a hasty dental visit.

As newFNP has noted previously, her clinic sees more carbohydrate addiction that it does drug addiction.  Therefore, this man was her first patient with a mouth destroyed by meth use.  She understand that the rapid dental decline is attributed to xerostomia, a lack of oral hygiene and an increased consumption of excessively sweet foods, but is that it???  Is that all it took for her patient to go from normal dentition to horrible dentition in the course of two years?  And why did it happen after he had been clean for three years?  (Or is newFNP just naive and he isn't really clean?)

NewFNP is swirling her own saliva around in her mouth as she types.  After that frigging root canal and crown, newFNP has no interest in dental interventions in the future.

In fact, she just might go brush and floss right now!  

Vote!

For Hillary.

Super Tuesday Eve

NewFNP is so excited to vote tomorrow morning bright and early at 7 o'clock.  

She is relaxed due to an unusually slow clinic day today, she has a Super Tuesday outfit all picked out and she is so frigging excited to cast an historical vote tomorrow.

The debate last night just fueled her excitement although it wasn't really a debate, was it?  It seemed like Clinton and Obama have to find topics to debate about at they are so politically similar.

NewFNP is very much looking forward to January 2009.  Soon, the damage of the last seven-plus years can begin to be addressed and undone.  Please let's have some universal health coverage and please let's really leave no child behind and not just say we will.  Please let's preserve abortion rights and access to pregnancy prevention services.  Please let's not invade Iran and let's deal with Iraq and Afghanistan.  

Oh, how newFNP will wear her "I Voted" sticker with pride tomorrow!

Oh no you didn't!

Perhaps it is self-serving, but newFNP likes to stress the importance of self-management of chronic diseases.  It isn't only because newFNP grows weary of repeatedly sky-high blood glucose levels in clinic, but also because it really is the key to secondary prevention and because, come on, just come the fuck on and help a sister out in controlling your diabetes and high blood pressure.  

A simple easy step in becoming active in the management of one's chronic illness could be learning the names of the frigging medications you are taking on a daily basis.  Hell, don't learn them -- just write their names on the back of a McDonald's receipt and put the note in your wallet!  

NewFNP suggested this novel idea to a new walk-in, out of control diabetic woman yesterday.  She explained that this will help her providers in making medication errors, poly-pharmacy and all.  Her reaction?  

She started crying.  

Seriously?  That is what it takes to make you cry, dear lady?  NewFNP cannot imagine what her personal life must be like, but she assumes it is not fulfilling.  

NewFNP took extra time with this lady as the clinic was exceptionally slow and newFNP's keen powers of intuition told her that this woman was not the picture of togetherness.  She thoroughly explained the new meds she was starting, how to take them and what they were for.  Frankly, newFNP did a much better job in explaining the meds to her than she does with many other patients.  She repeated pertinent info.  She wrote extra info on the prescription bottles.  She wrote instructions on a separate piece of paper.

And guess what?  NewFNP's MA came to the office to tell her that the patient and her cousin wanted more information because newFNP "didn't tell them anything."  

NewFNP reeled around in her chair and incredulously asked the patient if she had, in fact, told her nothing.  While her 50-something year old patient looked sheepish, her cousin looked utterly entitled and demanded more information.  

NewFNP gave them the requested info -- again -- and sent them on their way.

Many patients tell newFNP that their former providers don't tell them anything.  NewFNP is sure that this is true on many cases, but a situation such as this really showcases how patients and providers might experience reality differently. 

Is it a victim-complex thing?  It must be easier to be a victim of one's disease and of an incompassionate health care system than to take what control one is capable of.  

Is it a shitty Spanish thing?  Did newFNP just waste twenty minutes with this lady, speaking incomprehensible Spanish?  While possible in conditions other than diabetes -- say, for instance, Loa loa filariasis -- this explanation is less plausible with DM2 as newFNP finds herself providing education on this topic with alarming frequency.

Maybe it is a life-is-overwhelming thing.  

Frankly, though, whatever the reason, it kind of pissed newFNP off.  

The Michael Jackson Parenting Award

NewFNP sees plenty of examples of parenting which she hopes to never incorporate into her repertoire.  

Most, but not all, involve feeding practices.  These include Gatorade or chocolate milk in a baby bottle when a child is 6 months old, Hot Cheetos in the hands of an 18-month old, fast food on a daily basis and tamarind/lead candies from the ice cream truck.

Some "don'ts" involve discipline and behavior modification.  Spanking and name calling. NewFNP will take a pass on these.  Threatening a child with vaccines if they don't behave.  Telling them that a shot won't hurt.  NewFNP frowns upon these as well.

Others involve soothing techniques.  Feeding a crying child just to stop them from crying is a no-no in newFNP's Theoretical Guide to Child-Rearing.  

NewFNP does, however, approve of gently rocking and employing a soothing voice to calm a child after vaccine administration.  However, when a mother soothes an infant by lovingly saying, "It's not my fault... they're assholes.  Yeah, there there, they're just assholes," newFNP believes that she must modify her approval of the soothing voice technique.  

NewFNP hears a fair amount of crazy shit, but she had never heard a parent attempt to calm a crying child by calling clinic staff assholes.   

A class act indeed.

Buh-bye.

NewFNP walked out of work today.

Monday was the twentieth anniversary of the death of newFNP's mom.  NewFNP is not old enough to have passed this anniversary, but it came and went nonetheless.  NewFNP was feeling pretty sad about it and had a heartbreaking conversation with her younger brother in which mom's favorite flavor of ice cream was hypothesized about, but remained unidentified.  It seems more significant when the person is gone.

Well, nothing takes the sting out of that miserable piece of crap day than to get an e-mail noting that one will be working every frigging Saturday in February.  NewFNP feels compelled to remind everyone that Saturday clinic now begins at a soul-crushing 7:30 AM.  NewFNP promptly replied to this e-mail assault, employing words such as 'unacceptable' and 'disheartening' and 'go fuck yourself.'  OK, that last one was not verbatim but newFNP likes to think that she conveyed the sentiment in a very genteel fashion.

NewFNP's COO earnestly apologized and promised that he would change her schedule and that she would be working only two Saturdays, as per newFNP's agreement.

At three o'clock today and after seeing 20-something patients, newFNP received an e-mail reflecting the change.  Lo and behold, newFNP had a paltry one Saturday off and, friends, it was not the one she had specifically requested.  She attempted to broach the topic with her COO, but he was late for a meeting.

So newFNP left her patients in her exam rooms, donned her Tom Ford sunglasses and walked out, frustrated and feeling powerless.  

Granted, she only walked around the block, but she could have kept on walkin' if not for the risk of bodily harm via drive by shooting and of credit harm via student loan default.

But instead, she went back, did a couple of exams and then solved the problem.  

The huge drag is that it didn't even need to be a problem.  Dr. Dual-Ivy-League-Degrees offered to work one of newFNP's Saturdays.   The Real Dr. Mc Dreamy is working part time and she offered to pick up another Saturday.  All that really needed to occur was a little communication.

NewFNP is certain that poor communication is a problem in many community health clinics.  But newFNP is sick of it.  She is committed to community health, she is willing to be flexible, she has no intention of leaving.  Is senior management trying to force her out?  

Community health clinics have a hard enough time keeping providers.  NewFNP doesn't need a clothing allowance, but she does need to be treated with courtesy.

She'll probably need a Xanax when the March schedule comes out.

Your shoe problems - solved!

NewFNP is here to help readers in all pursuits to the best of her ability, not just in medicine but in general well-being as well.

As many of us in the health professions know, the perfect footwear can be elusive indeed.  Many of us opt for the Dansko clog, an ever popular and respectable choice.  Orthopedically sound and very European in sensibility.  

NewFNP, however, does not opt for said clogs.  Dansko clogs were all she saw during her years in nursing school.  Danskos and knitting needles.  NewFNP's fellow students were practically wearing down the sturdy Dansko soles while hauling fucking looms to class to make furry, multi-colored scarves.  Anyway, newFNP did try the Dansko clogs but she was always feeling precariously balanced in the ankle department, not to mention that they just didn't go with newFNP's overall aesthetic.

Enter the Sigerson flat.  OK, to be fair, the Sigerson Belle flat -- newFNP is not made of money after all.  The problem with the Sigerson flat is that they are truly frigging flat.  They are so flat that one may as well tape a piece of cardboard to one's soles and fashion a cute printed upper with some wrapping paper from Paper Source.  Cute as hell though they may be, that amount of flat is no good.

So what is a fashion conscious newFNP to do?

Enter the melange of Cole Haan and Nike.  NewFNP would have never thought herself one to tout the benefits of Cole Haan but, oh, that heavenly marriage.  If it weren't for the high price-point, newFNP would buy out the stock of Nike Air-soled G Series ballet flats.  NewFNP, after all, is nothing if not an OG.  And OG's need cute and comfortable ballet flats in pewter leather with satin trim or in red perforated suede with a little sweet white patent leather trim.  

NewFNP is a committed sale-shopper and recommends buying said exquisite ballet flats on sale as comfort doesn't come cheap from ole Cole Haan.

Burn baby, burn.

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

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

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

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

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

Judiciously liberal, of course.

TV junkie

NewFNP has enjoyed her weekend. Hairdo. Facial. NYT Crossword. Juno. (Better late than never.) And, today, newFNP has indulged in a guilty pleasure: TV.

NewFNP generally does not have cable, but has something called "antenna service" through her local rip-off cable company. Otherwise, she could not watch any TV at all, not even The Office or How I Met Your Mother and that is just not realistic. But every once in a while, her rip-off cable company graces her with basic cable. She never knows how long it will last, but she has enjoyed fully four hours of a frustratingly glorious program: What Not To Wear.

NewFNP would kill to get on a program that gave her five grand to go on a shopping spree in SoHo. Plus free hair-do and a little make up advice? Please. And these ladies get all pissy about having the opportunity to throw away their Kohl's and softer side of Sears wardrobes! Puh-leez!! Say goodbye to the puffy paint sweatshirt and Christmas cardigan and hello to Olive & Bettes and Bloomies on Broadway.

NewFNP would be such a better NP if she had five thousand dollars worth of free clothes. She would even promise to read peer-reviewed journals on the subway rides between boutiques!

Dare to dream, newFNP. Dare to dream.

Dream is just what newFNP will do on her day off tomorrow. Dream a little dream of fashion.

Shiver me timbers!

NewFNP was a huge fan of the Pirates of the Caribbean movie. Not the one where the guy played the organ with his face tentacles and Johnny Depp was swallowed by a giant vagina, but the first in the trilogy in which a swashbuckling Johnny Depp was swarthy and sexy with his pirate eyeliner and his pirate shirt and his pirate vernacular. NewFNP, however, did not adopt the pirate fashion and make it her own.

Apparently, however, the new nutritionist at newFNP's clinic was so moved by pirate couture that she has incorporated it into her daily wardrobe.

When newFNP starts a new job, she wears some sensible yet flattering trousers and a cashmere sweater with some low heels or flats her first day. She's not all pearls and Lilly Pulitzer, but she tries to put together something smart.

What she does not wear is a wide teal stretchy headband with a high, loose, devil-may-care ponytail, a black sweater, teal herringbone trouser shorts and black lace-up knee high high-heeled boots. That is exactly what the new nutritionist was sporting during her meet and greet. She must have left her parrot and eye patch in the car.

NewFNP wonders how she will do her nutrition education. Will she be all: Arrrr! Me bonny lass - eat ye veggies or ye shall walk the plank. Will she advocate for Pirate's Booty over Hot Cheetos and, if so, is she part of some pirate mafia that gets a kick-back?

NewFNP is actually quite thankful to have the pirate nutritionist on board. Since the recent departure of our gaudily-dressed dentist, newFNP's clinic has been woefully lacking in fashion mishaps such as the camel toe and work no-no's such as the low-cut blouse/Wonderbra combo.

Looks like things are picking up! Arrrr!

T.G.I.F.

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

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

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

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

What a lousy 10% to be a part of!

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

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

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

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

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

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

Community Health Ink

Long before newFNP was newFNP, she worked at a little county health department in the city where she completed her undergraduate studies. One patron of the health department was a fellow who had his face tattooed. He didn't have anything specific, just a lot of black ink obscuring his face. The effect screamed both "mental illness" and "don't talk to me - I am dangerous." Perhaps this was like a warning to would-be interlopers. It worked on newFNP; she never talked to the dude.

NewFNP has seen her fair share of hideous tattoos at her clinic. Bad butterflies, homages to dead loved ones, gang affiliations and plenty of crosses and dots in the web of the hand between the index finger and thumb which newFNP presumes to indicate gang membership or a history of incarceration.

However, there are some tattoos that just burn an indelible image in one's mind. Could anyone forget the image of the masturbating lady proudly displayed on the leg of one of newFNP's young patients? His mother must have been so proud. Imagine newFNP's surprise when a second patient had a strikingly similar tattoo! She had no idea there was such a market for these forays into the repulsive and permanent.

Well, Dr. Dual-Ivy-League-Degrees had a patient today who may have held the gold medal in repulsive tattoos. Apparently, this chap had a lady - naked, of course - tattooed on his abdomen, legs spread widely and intersecting at his umbilicus thereby allowing his belly button to form her anus. Classy and thoughtful! It must take a real talent to envision the design and then make it come to fruition without giving the lady one leg shorter than the other or some other such defect. Good thing the guy didn't have an outie! That would just be gross.

NewFNP presumes that these guys are straight as she knows no gay men who objectify women in this way. But what newFNP can't quite wrap her mind around is who exactly are the women who have sex with these guys? How low can one's self esteem get?

It is rare that newFNP sees women with such patently offensive tattoos, but she does recall one woman with a tattooed necklace that reads "Fuck niggaz and money" in two-inch script. More sad than offensive, really - at least in newFNP's eyes. NewFNP wonders who has screwed over this woman so incredibly that she thought to permanently emblazon her chest with this statement. Any newFNP doesn't quite understand the 'money' part. Apparently, this woman does not have six-figure student loan debt to repay.

And a final question: who does these tattoos? Perhaps they could do us all a favor and be trash collectors or dog catchers or captains of industry, huh?

If the shoe fits

If newFNP didn't have photographic documentation of herself salsa dancing and Corona-drinking in a far-far-away city a mere five evenings ago, she would swear that she had been trapped in her urban community health clinic Gulag for ages.

NewFNP wants to storm into the packed waiting room and scream: People! Let's band together and stop this nonsense! You have a cold? Go home! You have diabetes and ate a doughnut, a tamale and a double mocha frappuccino before your appointment? You're fired!

And those would be the easy cases. Today, newFNP's cases were not so.

Influenza? Check.

Child sexual abuse? Check.

Crying overweight ladies (plural) who don't want to have sex with their husbands? Check. (Prayer - please, please, please do not let newFNP ever fall into this group!!)

Parent who cannot name her child's apparently chronic, perhaps genetic, illness? Check.

NewFNP is not a parent, but if she were, she is pretty sure that if her child had some inborn error of metabolism or some genetic defect, she would at the very least have the wherewithal to write down the name of the fucking thing on a sticky pad. This would hold true even if newFNP were not an FNP. If newFNP were a fancy nail salon girl or a go-go dancer or even a rodeo clown, she would know enough to learn the name of the condition. Even more so if she herself had undergone genetic testing and had some genetic-something or other, as her patient's mom had.

When one spends nine years in post-secondary education, one's bar for normal intelligence is so absurdly skewed. Friends, newFNP is living 'regression to the mean' and this lady was at least two standard deviations below! NewFNP thought that everyone was like herself and her super-education friends.

Wrong. Oh sweet Lord, how wrong she was.

NewFNP hates to just chalk it up to 'stupid,' but sometimes the shoe fits. Can newFNP write "Mom not so bright" in the progress note? It only seems fair to give the next provider fair warning.

A fine how do you do

Outside of clinic, newFNP's life is going swimmingly. She's got some cute new sneakers and slimming workout pants, her romantic life is picking up and she bought a ceramic flat iron which effortlessly turns newFNP's curly mop from wild to sleek.

Clinically speaking, not so much. It's not that the patients are any more challenging or frustrating. No, it's that, starting this Saturday, newFNP's clinic is open from 7-fucking-o'clock until 3:30. Formerly, Saturdays were a merciful 8-to-2. This vicious change was announced in an e-mail this week. No opportunity for discussion, no mention of increased salary due to extended working hours. Just an 'Oh, by the way...'

Seven o'clock, people? Seven? Come on! NewFNP isn't even a wild party girl, spending all night in the club shaking her ass to reggaeton while downing Red Bull and vodka! All she wants is to enjoy a few glasses of Pinot Noir on Friday night, maybe watch a movie or paint her toenails and then peacefully sleep until 6:30 and still make it to work on time.

NewFNP is none too pleased.

When in grad school, newFNP frequently saw students, whom she presumed to be undergrads, walking around campus in their PJs. Not even cute Juicy sweatpant-PJs, but Spongebob flannel pieces of crap. Can newFNP wear velour Juicy sweatpants to work on Saturdays? They're a hundred bucks, for Christ's sake. It seems a shame to only wear them at home.

2008

It's always tough to return to work after Hanukkah, Christmas, newFNP's birthday and New Year's Eve. It's even tougher for newFNP when her plane lands thirty minutes late and she returns to her apartment at 12:30 AM and is so enthralled with her book that she just cannot put it down and then all of the sudden, it's 1:30 AM and newFNP utters "fuck" and switches off the light.

Seemingly, five minutes pass and newFNP awakens to the sweet sounds of NPR and again utters "fuck" and starts her day. Her day which ended 33 patients later.

Fuck 2008 so far. Thankfully, bad weather is in store so there will perhaps be a lull in the patient flow.

NewFNP is in the home stretch. Her service commitment ends this year and she will be a free agent. NewFNP, however, is a glutton for punishment and is eagerly awaiting the application for another two years of indentured servitude in order to pay off more loans. If only community health paid like professional sports, newFNP would not still be living in a one bedroom apartment and cursing her six-figure student loan debt.

Damned fancy schools with their Latin-inscribed degrees!

School debt and overworked days aside, newFNP is looking forward to yet another year of sharing stories. Truly, how could newFNP ever leave her ridiculous practice? Do stories like these exist in private practice??

The saga continues

Cocoa Brown is fucking crazy.

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

One might call this kind of crazy "felonious."

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

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

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

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

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

Cuckoo for Cocoa Brown

NewFNP's readers are already familiar with our good friend Downtown Cocoa Brown. As it turns out, she not only had a culture confirmed herpes infection, but also had a bonus STD: syphilis!

Hooray!

NewFNP, upon receiving the result from her lab and seeing the reactive FTA with a 1:8 titer, called her local public health department. She asked the helpful STD man if he had any record of having ever treated Ms. Cocoa Brown for said treponemal infection. He had not. NewFNP then proceeded to call Cocoa and ask if she had ever been diagnosed or treated for syphilis. She had not. NewFNP strongly encouraged her to return to the clinic A.S.A.P. in order to glean a better syphilis-related history and to start her some some sweet Pen G. Oh, and in the meantime, do public health a favor and keep those sweet legs tightly closed, would ya hon?

This was Tuesday. She swore she would be in Wednesday at 8:30 AM. NewFNP even requested an overbook. Therefore, one can imagine the importance newFNP placed on this visit. Around 9:30 on Wednesday, newFNP received a phone call from Cocoa's friend, the vagina voyeur, noting that they were a little on the late side in coming in for the syphilis appointment but that, not to worry, they would be there.

The dynamic duo never showed.

Again, newFNP feels compelled to point out the differences between her experience as a patient and that of her patients'. If newFNP has a blemish, she is powerless to not treat it. And she is talking about a micro-papule that she and only she can appreciate while her otherwise dewy and glowing skin is illuminated in the magnifying mirror. Intralesional kenalog STAT! If newFNP's vag* doctor told her that she had motherfucking syphilis, she would be destroying herself with penicillin!

NewFNP received a call today from the friend. The reason that Cocoa Brown had not returned to the clinic is that her friend's foot hurt "real bad." Ever heard of a bus? Taxi? Tricycle? Walking?

They swear that they will be there tomorrow. NewFNP, alas, will not. Her new work buddy, Dr. Dual-Ivy-League-Degrees, will. As sad as the case may be, newFNP knows that Dr. Dual-Ivy-League-Degrees will have quite a time with these two.

* rhymes with badge

First base.

NewFNP found herself in something of a clinical pickle today. She has a patient for whom she has been caring for his diabetes for quite some time now. However, he had not been to clinic in over a year when newFNP happened to run into him last week as he was exiting his dental appointment.

"How are you?" he asked, in Spanish of course, as he gave newFNP a warm hug - a practice of several of newFNP's patients. "How was India? Are you married?"

"India was great," newFNP replied. "And I'm single."

He proceeded to tell newFNP how he was in the midst of a divorce and that he would take all of newFNP's worries away by making her his second wife. Nice gesture, but newFNP will decline with a wave of the hand and a shake of the head.

Fast forward two weeks and here this gentleman is in newFNP's exam room for diabetes care. He told newFNP that he and his wife were considering divorcing because he, at age 45, wants a child and she, at age 50, is unable to provide him with one. NewFNP noted to herself his mid-life crisis, practiced supportive listening and attempted to steer him back toward the safer ground of DM2.

He, however, was not to be swayed. We chatted a little more about decisions, how one never knows what life will hand them, blah blah blah. What is this, talk therapy? After some more chatting and a sprinkle of dietary education thrown in for good measure, newFNP stood up from her rolly stool and declared that it was time to go to the lab.

At this point her patient stood up, went to embrace her and kissed her. On the lips. No tongue, but still. He then invited newFNP to "have babies with him." He was joking, of course. Right? NewFNP blushed eight shades of red and told him to knock it off.

What a bummer. NewFNP used to look forward to her visits with this intelligent and, today notwithstanding, thoughtful patient. Now she needs to wear a teeth guard and perhaps some Mormon underwear before she enters the room.

Damn.

Balls - redux.

When purchasing her new car earlier this year, newFNP felt confident that it would not be tampered with when she parked it in her clinic's ghetto-esque area. Why, you ask? It is because, time and time again, newFNP noted that all around her were big trucks with flashy 16-inch rims, SUVs with the same, minivans with those spine chilling stick-figure family stickers, or piece of shit junkers with piece of shit spinning rims. NewFNP bought a hybrid, a very hybridy-looking hybrid. They are not so common or coveted in newFNP's hood.

NewFNP loves cars. In her dream world, she would have her sweet hybrid and she would have a sweet Audi S6 all-wheel drive wagon for snowboarding with George Clooney. But she would not, under any circumstances, buy a big truck, fashion a skull whose eyes glowed red when she stepped on the brakes to the trailer hitch and hang from its truck underbelly a huge pair of swinging rubber bull testes.

Yet newFNP has seen this accessory more than she would have liked to. For the record, she would have liked to have seen it exactly once, just for shits and giggles, but to have seen it repeatedly feels somewhat abusive. Does newFNP really need to be hypnotized by faux balls as she leaves work?

Who hangs these balls from their truck? Do they have female partners who deign to be seen in such a masculinely adorned vehicle? Do they feel appropriately shamed when they go to the bull-ball store and weigh the decision regarding color? Do they cup their purchase in their palms and feel pride? And - really - who chooses blue?

NewFNP knows the message that these chaps are trying to put out there. They are saying, "Do not fuck with me. Smoke comes from my nostrils when I am incensed. Furthermore, my testicles are laden with semen and my semen, if you must know and - trust me - you must, is the stuff of legend. In fact, I am quite certain that there exists a tome entitled 'La Leyenda de mi Semen.' My erections are formidable."

The message received by newFNP is more like this: I am compensating for my small, poorly functioning penis, I do not know where the clitoris is, and I drink too much.

Can't we just go back to sexy mud flap ladies?

Downtown Cocoa Brown

NewFNP has rarely, if ever, found herself in the position of requiring - let alone desiring - a friend's presence while at the doctor. Truth be told, she would rather keep that part of her life private. Especially as it relates to her lady business. Good news? Great! Bad news? Private!

However, if newFNP's patients want to drag their sisters/friends/cousins to their appointments, who is newFNP to deny them? Of course, newFNP asks family members to exit the room during sensitive histories or exams, but respects it if her patients want to use the buddy system.

This morning, when newFNP read the chief complaint of "boil on her vagina," she felt a little glee at the thought of incising and draining what she assumed to be an abscess. It's been a long time since newFNP performed any mini-surgery and, frankly, she's been missing it.

Alas, it was not to be.

NewFNP received permission to make this a group visit and proceeded to ask her patient who, by the way, had a BMI of 41, how she could be of help. Her friend, whose BMI was easily 50-plus, piped up with, "She got a boil on her cocoa brown!"

NewFNP elicited the pertinent history and got the patient into the lithotomy position - no easy task - and began to survey the region when her friend came around to get a lay of the land as well. NewFNP quickly maneuvered the makeshift drape in order to cover her patient.

"Whoa, whoa, whoa," newFNP said. "Is it okay with you if she looks?" NewFNP's patient, astoundingly, gave her the go ahead and her friend jumped on in.

Again, newFNP would prefer that all of her friends would just stay the hell out of her own cocoa brown. Permission to view the pelvic exam denied!

This lady's cocoa brown wasn't exactly rocking the cocoa puff, per se, but more of the cocoa herpes. When newFNP asked her if she had a new partner, she answered in the affirmative. After determining that this was a male partner, she asked if he was a good guy. Her friend emphatically answered that he was, in fact, not. To which, newFNP's patient informed the room that she would no longer be "fucking with him."

Good then. NewFNP provided some safer sex counseling, offered further STI screening, and bid these two fine ladies adieu.

Go Bruits!

NewFNP knows a thing or two.

For instance, she knows that she should not wear black trousers with brown shoes, even if the shoes are Sigerson Morrison and cute as hell. She knows that grown men should not wear bikini underpants. In fact, if she were pressed, newFNP would assert that no men - regardless of age - should wear bikini underpants. Not even George Clooney. Because if there is anything that could render an otherwise ridiculously handsome and obviously virile man pathetically unattractive, it's bikini underpants.

NewFNP also knows that when one auscultates a carotid artery, it should not sound like there is a frigging Harley Davidson Chopper racing through at breakneck speed. And it sure as shit should not be happening on both sides. No, the finding of bilateral rumbling carotid bruits is undesirable. In concert with a fasting glucose of 392 and a BP of 204/90, it makes newFNP's eyes glaze over and forces her to consider a career as a nail salon girl. In an upscale salon, of course.

If newFNP were to adopt a "half-full" approach, she would be gratified to observe how well one can look and for how long one can push on while one's blood supply to the head is compromised.

What's that, you say? You're dizzy? No shit.

The reason that newFNP's is able to observe just how long a person can survive with said pathophysiology is that this patient, like so many others, is uninsured. Sure, when she went to the ED after passing out in her chair for no apparent reason and newFNP called the attending physician to give a little carotid bruit heads up, one would think that this patient would have exited the hospital with, oh, let's say having had a duplex ultrasonography and an MRA. One would be wrong.

NewFNP sent off the referrals today. Frankly, until this lady gets health insurance, newFNP is not hopeful that her condition, which clearly warrants an urgent evaluation, will be so.

Did newFNP mention that this patient is 57 years old? Not exactly a spry fifty-seven.

Yeah, you're in the right place.

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

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

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

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

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

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

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

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

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

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

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