Small world (after all)

As you may recall, newFNP was feeling fed the fuck up with her clinic.  This prompted her to send her CV to her local major university/research center/medical center.  This was on Saturday at 5PM.  She was expecting that they would call, but that they would call in a month. 

They called Monday afternoon.  And not just HR -- the medical director of the position for which newFNP applied.  She was seeing patients and was too astonished to answer the phone.

She was recounting her tales of woe and her desperation and job-seeking and rapid return phone calling to her pal and Scrabulous nemesis during the walk to the Death Cab concert Monday night.  "Hmmm," he said, "That sounds like the project that CHO works on."  Confirmed.  An MPH colleague, to whom newFNP was a mentor during MPH orientation, has worked there for years.  

Last night, newFNP was dining with her other public health gal-pals in honor of a great public health pal visiting from her South African international health job and was detailing yet again her frustration with work and her possible venture into academic medicine.  

"Come to South Africa!" newFNP's friend stated.  Interesting, but pass.  Amongst other things, if newFNP ever wants to get married, it seems as though a move to South Africa might decrease those odds.

As she described the research area, another friend stated, "My brother is doing that same kind of research."  

"What's his name?" newFNP asked.  Medical Director.  NewFNP had spent a half an hour locked in an exam room, talking to him on the phone just hours before.   

Has newFNP recently mentioned that she lives in a really major, major metropolitan area?  This project has a staff of ten.  Ten.  NewFNP isn't mystical or religious or a believer in fate, but these coincidences are somewhat testing her beliefs (or lack thereof).  

And she met with the medical director today.  He didn't promise newFNP anything, but he did say the magical words, "Well, you are very well qualified."  

Word.  NewFNP has mad qualifications.

If you can't take the heat...

NewFNP is hot.  She is - sadly - not 'hot' in the new hair-do, flattering trousers, sassy flats sense of the word.  No, she is talking about the Holy shit! Who turned up the heat and why in the hell don't I have central AC kind of hot.

And newFNP is also frustrated.  This is not a good combination.

NewFNP is sending out a cry for help.  NewFNP does not like herself much of the time anymore when she is at work.  She is mean.  She hears the harsh tone of her voice and cringes.  She is endlessly frustrated by the half-assed work of the support staff.  Each and every day, she is correcting other people's mistakes and dealing with other staff members' shitty attitudes and disappointed by the lack of improvements in the system despite her efforts.  She hears that people have called her bossy, which is true, and a bitch, which has been true but is not something newFNP is in her outside clinic life.  NewFNP wants to not care about what people think, but she does.  And newFNP does not want to be a bitch.

NewFNP spends so much time looking for unfiled labs, asking her MA to find unfiled labs and doing laps around the poorly designed clinic in an attempt to find her MA in order to ask her to find unfiled labs that she could probably see an extra 1-2 patients per day if this one issue were to be solved.  She is fed up with the growing piles and piles of unfiled charts on the floor of the file room while the clinic staff sits and chats about whatever crap it is that they talk about.  She is frustrated that the very young and very overwhelmed clinic manager is impotent when it comes to actually managing the clinic and the staff.

As an aside, there are many reasons that drive the resistance against change in newFNP's clinic.  When newFNP eventually leaves, she'll share them with you and it will make your heads roll.  But the infrastructure is so unique that it would be a dead give-away if anyone in the know was to stumble upon the blog.

So what to do, what to do?  NewFNP doesn't want to leave, but she doesn't want to be a bitch and she doesn't want to be frustrated.  

Her CV looks pretty slick.  Will her local major university -- and her alma mater -- think so too?  Because newFNP submitted it in an act of sheer desperation.  She is looking for options.  And a pension.  And a salary increase.  But to leave would mean giving up what brings newFNP joy - caring for her patients.  

A conundrum indeed.

Thankfully, newFNP has the Death Cab concert, her super-duper friend from South Africa visiting and not one but two grad school pals visiting this week.  She'll be too busy with her real life to worry about her work life.

Atypical.... and typical

On the day of the first power outage at newFNP's clinic, there was a teenage boy waiting to be seen who had - the day before - fallen down a flight of stairs, broken his nose, split open his lip and fad a face that resembled Chunk from 'The Goonies'.  He had been seen in the ER and just needed a referral to get his face fixed.

NewFNP talked to him and his parents outside, grabbed a flashlight with the brightness of a penlight, went inside the cave-light clinic and finished the kid's referral.  This was month's ago, was no big deal and, frankly, newFNP had forgotten all about it.  

Apparently, the CEO had not.

During the clinic's staff meeting, he acknowledged newFNP's contributions in front of the entire staff.  NewFNP can imagine how he told the story of her relatively minor contribution to patient care and then called out her name several times, only to have someone say the inevitable: She's still seeing patients.

NewFNP's one moment to shine and she missed it!

Oxy

In case anyone missed the memo, community health is challenging.  It's not only that patients are ill and uninsured and have more medical and emotional needs that the clinic and any given provider can reasonably handle.  

It's also that the patients just don't 'get' the system.  

For instance, newFNP had a charming but terminally ill seventy-five year old woman walk into clinic today.  The woman has cancer.  How does newFNP know this?  Well, it helps to have pathology reports noting lung cancer and metastatic adenocarcinoma.  However, even without the reports, newFNP wouldn't have missed this one.  

She wasn't on oxygen, she didn't have a tracheostomy.  So how could newFNP have known that she had cancer?  Did she call Miss Cleo's psychic hotline?  Does she have x-ray vision?

Nope, it's because the woman had two huge visible tumors.  One was on her anterior chest wall, about the size of a baseball and just as hard.  The other was on her abdominal wall.  It was rock hard as well... and draining.  And it was large.  Really large.  Hugely crazy large.  Bigger than Posh Spice's fake boobs.  NewFNP is talking 8-by-6 inches large.

Now, this woman has known since January that she has inoperable cancer.  And where might her oncologist be?  In a state some twenty-five hundred miles away from newFNP's clinic.  She stated that she got bored and just wanted to get away.  NewFNP appreciates that, if one is dying, they should do whatever the hell they please.  Travel the country, visit the ghetto!  

But just one thing - get your oxycodone refilled before you leave.  

As newFNP has previously noted, the walk-in scheduled med refill is not one of her favorite visits.  But when you have very obvious cancer, newFNP doesn't even think twice about writing that oxy prescription.  Knowing what lay ahead for this woman, newFNP accompanied the prescription with a referral to the palliative care team at our local public hospital.  

Skills Lab

This is what passes for a rich Monday evening in newFNP's life - the new Death Cab for Cutie album on heavy rotation, an 80-cent pig's foot from the El Salvadorean market and some borrowed instruments/pilfered sutures from clinic.  

Good times.  

 

Hold on

Clinic is a roller coaster.

In one room, you have a scrawny four-year old in full Spiderman regalia flexing his little biceps telling you to look at his muscles while awaiting you in another room is a social worker from children's services telling you that she needs to remove two children who are currently in the clinic from their father's custody and she wants your help.

NewFNP chooses the first room. She'll take a pass on the second. Alas, the second room chose her as well.

NewFNP has sympathy for people who have addiction problems. But it is hard to have sympathy for parents who cannot get it together to find help for sobriety while they are pregnant. When your newborn screens positive for cocaine, that is - frankly - bad. It's just bad. There is just nothing good about the fetus-cocaine combination. NewFNP received a phone call from the hospital letting her know that she would be seeing this baby for her newborn exam and that the children - the newborn and her 18-month old sister who shares a name with a slang term for marijuana - were in the custody of their father under the supervision of the department of children's services.

She was unprepared for the social worker to appear in clinic, to tell her that the dad's tox screen was positive for marijuana, and to tell her that she would be taking the children into protective custody after newFNP did her newborn exam. And, oh, by the way, would newFNP help her?

This is where newFNP is a huge spineless jellyfish. She has this frigging affliction of wanting to make life easier for others, all too frequently sacrificing her needs in the process. What she should have said is, "No way. NewFNP will do the exam, but you call the police and you do not put newFNP in the position of betraying her patient." But the social worker had already stated that she didn't want to call the police and escalate the situation, a point of view to which newFNP is not entirely unsympathetic.

So newFNP did the exam and - it pains newFNP to say - lied to the father and told him that she needed to re-weigh the six-pound baby to ensure accuracy. She exited the room, baby in hand, and deposited the newborn in the hands of social worker #2. She returned to the room, laden with guilt, with the social worker and the clinic manager. The social worker explained to the father why the children were entering temporary protective custody. As the shock wore off and the reality set it, this young man - covered in gang tattoos - wept. He cried. He hit the wall. He lifted his shirt to dry his eyes, revealing even more gang tattoos.

NewFNP knew that she was betraying the implicit trust of the provider-patient relationship the entire time she was participating in this shady operation and she felt appropriately guilty about it. But when she saw all of the tattoos, she, for the first time at work, actually felt scared. She has seen National Geographic Lockdown and she knows that one doesn't get initiated into a gang by knocking mailboxes over or kneeling behind your buddy while another friend pushes him and makes him fall. No, gang initiation generally involves a more illegal activity. Like killing. And the time when one's children are taken into protective custody is generally not the time when one is thinking clearly. NewFNP isn't given to paranoia, but she did feel like she had foolishly placed herself and her clinic in potential danger. She called the social worker the following day to talk with her about this, but she just got a voice mail.

NewFNP went for a beautiful bike ride in a nature preserve after work yesterday. It's all single trails and fire lanes and deserted bunkers and really, really, really long hills. Fun going down, not so much going up. She got to the top of the hill and stopped. She looked out over the ridiculously beautiful view below her and attempted to prevent her heart from exploding and the lactic acid from melting her quadriceps and thought, "I am so lucky. I love my life."

NewFNP is sure that she is overreacting and that this guy will do nothing to further jeopardize his custody of his children, who he quite clearly adores. But she will listen to her gut if she is ever in that shitty position again. The answer will be no. Sorry, but no. No, newFNP will not aide and abet. She will wait to do the exam until the police arrive, but she will not take a child off the exam table and away from her father ever, ever, ever again.

The obstetrical history

When newFNP considers the perfect amount of children to have, she generally comes up with one number: two.  However, if newFNP does not get on the stick - so to speak - she will have exactly zero.

NewFNP's patients do not seem to share her values when it comes to parity.  Granted, newFNP has nothing but unfettered access to birth control and is also nursing a semi-paralyzing fear of parenthood.  Be that as it may, she finds the obstetrical history of her elderly patients who grew up in developing countries fascinating.

Today, she asked an 80-something year old lady how many pregnancies she had had.  Fifteen.  Fifteen.  How many births?  Fifteen.  Her vagina must hate her.  As is common with multigravid women in developing countries, some of her children did not survive infanthood.  Seven of her children died during the first year of life.  

It is not uncommon that newFNP's patients are grand-multips.  NewFNP has heard so many 10's and 12's and 14's when she asks about number of pregnancies, she is hardly surprised by the answers anymore.  But these women generally have some type of birth attendant with them.  Sister, mother, nurse, lay midwife, doctor... someone is generally there to assist in the birth.

One seventy-odd year old lady, however, gave birth alone.  Twice.  NewFNP was sure that she had misheard.  Alone?, she asked.  Alone.  No midwife?  No, no midwife.  Twice? Si, si, the patient assured newFNP with an amused smile on her face.

NewFNP's patient went on to tell her that she just had the scissors on hand, birthed the baby, tied off and cut the umbilical cord.  NewFNP's face must have betrayed her amazement.  Her patient explained that there was a woman in her community that gave her something to drink beforehand -- to give her strength.  What in the hell was in that drink and can newFNP get some of it before she goes to work on Saturdays at 7:30?

It's quite a contrast between prenatal care at the fancy hospitals here in the U.S. with ultrasounds at every visit and 3-D ultrasounds and CVS and amnio and EAFPs and episiotomies and forceps and fetal scalp monitoring and NSTs and epidurals and IV morphine and 25% or higher c-section rates.  NewFNP isn't saying that she isn't down for a little picture of the fetus action, but it is nice to remember that pregnancy and birth aren't diseases and that women's bodies are, in fact, designed to support the entire process.  

NewFNP's fantasy letter of resignation

Forgive the lapse into first person.

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

Dear Medical Director and Other Pertinent Senior Managers,

It is with absolute joy that I, newFNP, submit to you my letter of resignation.  Hooray!  To quote a decreasingly relevant but still important songstress, "Holiday-ay [oh yeah, oh yeah], celebray-ate [come on, let's celebrate]!"

I see that you are scratching your heads wondering why I, newFNP, may be leaving.  Is it the unreasonable workload, you may be asking?  It is not.  Is it the lack of support staff in the clinic? Not that either.  Is it the incessant drama?  Alas, I have grown immune to it.  Is it the working through lunch almost every day?  No, in fact, I, newFNP, think of that as part of my calorie restriction plan!  

Is it the fact that, despite our mutual agreement that adults with chronic diseases should have thirty minutes allotted for physicals, they continue to have fifteen minutes and I, newFNP, am expected to take good care of them in that time frame?  Ditto for new prenatals and IUD insertions.  No, I have begrudgingly accepted that I must see another patient faster in order to have a longer time with the more demanding patients.  I, newFNP, am a natural-born problem solver!  

Is it the fact that I, newFNP, earn $15,000 less per annum than the provider who referred the patient with the markedly enlarged prostate to nephrology?  I know, I know, I am not supposed to know the salaries of other providers but - guess what?  I do, and that still is not the reason I, newFNP, am leaving.  Is it the fact that, despite having brought concerns to you all several times, only to have you nod empathically and promise to address these aforementioned concerns, you do nothing?  Amazingly, no.  

As you can see, I, newFNP, am willing to put up with a shitload of crapola because I am a schmuck and committed to community health!  So you can go ahead and pile this dump-truck of crap on me and I, newFNP will stay!  I do not expect that you will thank me, only that I will receive my bi-weekly paycheck.  I must admit that you have unfailingly delivered in this!  I wonder if you laugh when you see how many hours I, newFNP, have worked for the amount of money you pay me?  Not that it matters.  As I have already noted, I am not leaving over paltry concerns such as salary.

No, I am leaving because you continue to fuck up my schedule.  That's right.  After almost three years of employment, you continue to change my day off and have appeared to have settled on Tuesday.  Well guess what?  No thank you, Sirs and Madams.  I understand that so-and-so has school and so-and-so has another job and so-and-so never works Saturdays.  Because I, newFNP, have demonstrated flexibility in the past, I see that you saw fit to take advantage of that yet again.  Why should I ever have doubted you?  You are a consistent bunch, after all!  Consistent in screwing up my schedule!

No hard feelings, eh?  

Taking this job and shoving it, fondly of course.

-newFNP

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

NewFNP is clear that she cannot say this to her supervisors, but she is unsure why they are so unfailingly unrealistic.  Is it wrong to hate them?  NewFNP thinks not.  Is it, after all, the natural order of things.

Tuesdays off?  Didn't we already go through this with the last inept scheduler?  

NewFNP is nothing but a hater tonight.  Not even a delicious homemade meal of sesame-encrusted seared ahi with organic broccoli and rosemary fingerling potatoes could extinguish her fiery distaste of her clinic and its retarded scheduling.  

He has AIDS

Truth be told, newFNP generally loves to be right.  It's not her best personality trait, but it is what it is.  She's working on it and nursing school certainly helps one learn how to say, "I was wrong."   

This is one case in which newFNP wishes she were wrong.  She had almost convinced herself that her patient was just seroconverting and that was why he had this malaise, this acute drop in immunocompetence.  As if all of her worry and her wishes and her day-off appointment coordination and letter writing could change the course of the pathophysiology at work throughout this young man's body.

But newFNP got her CD4 count today.  It showed his absolute CD4 count as less than 20.  His percentage of CD4s was three.  The low end of normal is 20%.  NewFNP's heart broke.

This patient has really touched newFNP.  It is probably for his loneliness, his isolation.  NewFNP has always been drawn to these people and has always wanted to show them that there is someone in this world who cares for them.  This is perhaps a result nature (newFNP is what she is) and nurture (losing her mom at a young age and all its subsequent emotional detritus).   Whatever the psychoanalytical insights, newFNP is willing to go the extra mile for these people.

It is probably also because this patient knows that newFNP is there for him and newFNP knows that he knows that he can count on her.  Today he told newFNP that she was the only one to visit him in the hospital and that he never feels shame when he sees newFNP.  NewFNP knows that he is keeping his diagnosis from the majority of people in his social circle so it felt good to hear that he felt cared for by newFNP and her staff.  He gave newFNP and her MA heartfelt thanks and a warm hug as he was preparing to exit the exam room.

Which was where the hug-fest ended and the pissed off newFNP began.  Her lab MA refused to draw his blood.  If he would have refused in front of the patient, newFNP would have stroked out.  Thankfully he had the good sense or good luck to refuse while the patient was still in the room.  He knew that the patient was HIV-positive because newFNP didn't want the patient exposed to all of the ill people in the clinic until he is on PCP prophylaxis and ART.  Therefore, newFNP's MA asked him to either clear the lab or draw the blood in the room.  

NewFNP is in a quandary.  She supposes that an MA may refuse to do a task.  But can the lab MA refuse to draw blood?  We have and use universal precautions for a reason.  We treat all patients with dignity and we treat all of their blood as potential pathogen-carrying fluid.  So how does newFNP approach this?  Education, newFNP supposes.  But she is just so pissed!  Is de-stigmatizing HIV only an activity for educated people?  God, newFNP hopes not.  We need some ACT UP in the lab!

Furthermore, why was this man discharged from the hospital without PCP prophylaxis and an appointment with an HIV specialist?  NewFNP is awaiting the hospital records, but is pretty frigging disappointed that he left only with a repeat prescription for his original fungal infection. Is it possible that the hospital staff chose to ignore his HIV status and not at all assess his immunocompetence?  Is that the care newFNP can expect when she sends her patients there?

More and more, newFNP is missing real public health.  She is missing the sense that her work is saving people, is preventing illness.  NewFNP is generally not to full of self-inflation, but she didn't go into healthcare to diagnose HIV when it is actually AIDS, to diagnose diabetes when it has already impacted eyes and kidneys and feet.  

It is so sad, so utterly disinflating.

NewFNP left work an hour after the clinic closed tonight.  She relished the only quiet time of her day as she made the abnormal lab list, she wrote a couple of e-mails that she hadn't been able to get to earlier in the day and she updated this patient's confidential HIV report, noting his AIDS-defining CD4 count.

She feels like shit tonight.  Calorie restriction be damned!  Ice cream, anyone?

Three-peat

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

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

Want that toenail removed?  Bring your own flashlight!

Period

NewFNP remembers her menarche all too well.  She was preparing to go to swim team practice while spending the summer with her grandparents.  Her coach, Aaron, was hot and newFNP was pretty heavily working a schoolgirl crush.  NewFNP's mom had had "the talk" with her some years before so newFNP knew what was happening and she was none too pleased.  

First period?  Swim practice?  Hot coach?  Bad.  

NewFNP's grandma, after congratulating newFNP on her passage to womanhood, called newFNP's mom to tell her of the news.  NewFNP's mom seemed happy and proud, clearing indicating to newFNP that all adult women were insane not to recognize menarche for what it felt like at the time: a disaster.  The only thing that could have made that experience worse for newFNP would have been if she would have been at her dad's house.

Which is exactly where newFNP's young patient was when disaster struck.

This ten-year old girl spends a lot of time with her dad and he brings her to each and every of her clinic appointments.  NewFNP knows them pretty well and thinks that this man is one of the best fathers newFNP has ever met.  Generally, he is really clear about his concerns or needs when he brings his daughter to the clinic.  So when he came in and told newFNP, in Spanish, that his daughter was here to see newFNP because she 'was developing', newFNP didn't quite catch his meaning.  When he told her that his daughter was now 'a miss', newFNP was equally stumped.   Bilingual newFNP?  Yes.  Bicultural?  No.  It took his daughter saying "I got my period" for newFNP to get on board.  

Dad asked newFNP to do some explaining and exited the room.  NewFNP let her patient lead the conversation.  There were some basic questions.  Will it hurt?  Should you carry supplies with you?  Will it come every month? Why do girls have their periods?  

Now, newFNP has never really given 'the talk' before and her recollection of her mom's talk elicits only memories of embarrassment and desires to return to her room and listen to some Duran Duran albums.  

So newFNP just talked about it medically.  She told her young patient that girls have periods so that they could have babies when they are older.  Her patient wondered how blood and having babies went together.  NewFNP talked about a nutrient-rich environment for babies to grow.  She drew a picture of ovaries, a uterus, a cervix and a vagina.  Clearly, newFNP will have to work on her talk and her art if she ever has daughters.  

The young girl looked at the drawing and took in all that had been discussed.  She took a pensive pause and asked newFNP, "Does the baby come out of the same hole as the period?"  NewFNP responded that it did.  Again, her patient paused although it was clear to newFNP that her mind did not.  "But that hole is small," she said, "and babies are big."

Amen, sister.  Amen.  

She went on to ask, "Why does having a baby have to hurt so much?"  No shit.  NewFNP has asked herself that several times.  And then she immediately downs her birth control pill.

We talked about bodies being made of muscles; about how even though we have periods, we don't need to have babies until we're older; about breasts and sports and school and growing up.  

She left, questions answered, ready to go back to being a ten-year old girl.  Dad shot newFNP a look of thanks and of pride yet clearly tinged with a bit of sadness because his little girl is growing up.  It was quite sweet.  

Home sweet home

NewFNP has just returned from a glorious long weekend with her graduate school pals. She ate good food, hung out with her friend's kids - one of whom called her Frank Gehry fish necklace a 'banana phone', drank too much wine and shopped in a very hipster area of an across-the-county metropolitan area.  It was a great weekend and newFNP misses her dear friends already, but it sure feels lovely to cross the threshold into one's own apartment.

Before newFNP departed, she checked in at the hospital where she had transferred her HIV+ patient.  He was admitted for presumptive PCP and was still spiking temperatures.  He was set to receive a blood transfusion for a hemoglobin of 7.2.  He was in isolation due to concern for TB.  

This is the guy that the paramedics gave newFNP a hard time about?  One of the paramedics actually asked newFNP, "Well, did you listen to him?" when she told him of her PCP suspicion. No, dickhead, newFNP makes it a practice to not examine her patients prior to calling for EMS. The vast majority of the paramedics are so great and sort of participate in the group effort we all undergo to attempt to keep our patients well/alive, but this interaction brings to mind another frustrating experience with EMS.  Last time, the asthmatic kid was admitted for several days.  This time, her patient is still in the hospital.  She talked to his nurse this morning.  IV Vancomycin Q8 hours and still spiking temps.

NewFNP wishes that she wasn't right about this one.  But she also doesn't want to have a fight in the hallway with the stubborn paramedic.  NewFNP - believe it or not - is trained to make decisions such as when to send patients to the hospital and she doesn't want to duke it out in the hallway.  And, with this guy, she got the distinct feeling that he just wanted to blow off the transport and make a point of questioning newFNP's judgement.  Is it possible that he didn't want to transport someone with HIV and a fulminant facial rash with a suspicion of AIDS?  NewFNP hopes that is not the case.  She would much rather have him think that newFNP is a big fat idiot.  

NewFNP wishes that she knew more about HIV management.  Of course, newFNP would not be able to provide such services in her clinic without social work and drug assistance and support for remaining clean & sober.  Nonetheless, newFNP feels like her HIV management knowledge hits an abrupt wall soon after diagnosis.  Perhaps a good CME topic.

Seriously... again?

NewFNP really wanted to do primary care.  She wanted to be out in the trenches, preventing diabetes and HIV and obesity and the like.

What a fucking sucker newFNP was.

In newFNP's clinic, there is a paucity of true primary care.  There are many reasons for this, not the least of which is that newFNP's patients come in the the clinic already sick.  NewFNP spends as much time putting out fires (read: lowering>500 blood glucose) than she does educating diabetics about the pitfalls of the all-carb breakfast.

But newFNP's clinic is also lacking in early intervention.  It's like the frigging uncontrolled disease rodeo and the providers need to lasso those buckaroos back into control.  It sucks.

Today's case in point.  Last week, a 31-year old man came in to see newFNP with what newFNP determined to be a diffuse cutaneous tinea infection - essentially covering his face - and a 23-pound unintentional weight loss over the previous five months.  Although he denied HIV risk behaviors, newFNP tested him.  

When his result came back positive, newFNP attempted to reach him by phone to get him back into the clinic.  It has been an ongoing struggle for our front desk staff to remember to ask for updated contact info and this was one patient whose new phone number slipped through the cracks.  NewFNP felt horrible in learning this.  How in the world would she contact him and get him into treatment?  How could she have let public health down and not updated his information herself?

Fuck that, newFNP decided.  She grabbed her clinic manager and walked the five blocks to his house today.  Pretty much every staff member that heard of her outreach plan looked at her as though she had utterly lost her mind.  One asked if she was bringing a gun with her.  She did not.  She knew that the address may not have been correct, but she needed to fill out the HIV case report and thought it best if it was completed to the best of her abilities.

Now, newFNP works in a metropolitan center that is rather renowned for its urban blight.  She is generally so busy that she doesn't leave the confines of the clinic during her work day.  But today she ventured out and really saw what all the fuss is about.  Sure, drive by shootings and gang warfare get all the press.  But what the fuss is about is a lot of loafing and mid-day drinking.  Perhaps, on a larger scale, one might say that this fuss is about unemployment and bleak future prospects, but newFNP has been so damned heavy lately - she just can't go into all that.  She, thankfully, was spared the gang-related drive-by shootings.

As she walked those five blocks, newFNP was struck by how an eleven mile drive really transports newFNP into a whole different world.  When newFNP hits up the liquor (OK, wine) store, she rarely - if ever - sees groups of people hanging out or talking on pay phones, all the while with their toddlers in strollers drinking extra large juices or their school-aged children decidedly not in school.  When she has a weekday off and walks to the store, it's rare that she sees groups of middle aged guys just lounging on the front lawn, shooting the shit and drinking Budweiser tall boys.

But that is exactly what she saw as she walked up the street, clinic manager in tow, and cautiously approached the address listed on his chart.  NewFNP's clinic manager inquired as to the patient's whereabouts, to which one man replied, "You mean the guy from Honduras?"  Hmmm... that is not information with which newFNP was armed.  Another guy said, "Oh, you mean the one with the spots on his face?"  Bingo.

According to the Budweiser posse, he did not in fact live at the house, but across the street. One gentleman offered that newFNP's patient was cooking in the back and went off to retrieve him. The men told newFNP that there was a point during which her patient could hardly get out of bed and they wondered what was wrong with him.

It's safe to say that her patient was surprised to see her.  She asked him to come with her the clinic and he agreed to be there a couple of hours later.  When he arrived, this 31-year old man's temperature was 103.1.  His lungs were junky - wheezing and rales.  His O2 sat was 96%.  

Not only did this guy learn of his HIV+ status today, he was transferred by ambulance to the hospital to rule out pneumocystis carinii pneumonia, an AIDS defining diagnosis.  

It was a heartbreaking appointment.  He lives alone.  His entire family is in Honduras.  He has no phone.  He has been clean and sober for a mere six weeks.  He told newFNP that it would have been better had he never known, that he would be better off dying.  

NewFNP told him about the advances in care and medications, about the many services available to HIV-positive people in this huge city, about how he has the resources, albeit limited, of newFNP's clinic to support him.  But newFNP knows that this is a socially isolated, marginally literate, extremely poor man whose social circles may be more likely to shun him than to support him.  Honestly, newFNP is as concerned with his emotional well-being as she is with his physical.

And, for the second time, newFNP gave an HIV+ test result not when the patient was generally well and had natural defenses intact, but when the patient was ill.  When they likely had AIDS at the time of their diagnosis.

That is not right.  It's not right.

Mother's Day 2008

NewFNP is at home, listening to Neil Diamond in honor of her mom, Nancy, who died twenty fucking years ago at the age of thirty-eight.  She had a cerebral aneurysm.  But that is the least interesting thing about her.

She trained as a journalist but worked in public affairs after her divorce.  She instructed newFNP to call her every day after she returned home from school, which newFNP did without fail.  She was hilarious.  She watched Magnum PI regularly and remarked more than once that Thomas Magnum had cute buns.  From newFNP's standpoint, she seemed to make people around her - her friends and colleagues and family - happy.  

She loved Asian design and had issues of Architectural Digest lying around the house.  She had a license plate frame on her black Nissan sports car that said, "Nancy - 90% Angel" which brought newFNP absolutely nothing but mortification.  She had thick calves which newFNP had the misfortune to inherit.  But she also had sparkling blue eyes and newFNP got those too.  She wore Obsession or Chanel No5.  She used Clinique and blue eyeshadow.  She was never without polished nails.  She doodled when she talked on the phone.

She was a single mom since newFNP was six and her younger brother two.  She allowed her house to be overrun by pubescent girls once a year for newFNP's birthday sleepovers, which always involved a lot of pizza and horror movies and tee-peeing some poor soul's house.  When newFNP had to stay up all night in order to be sleep-deprived before having an EEG after having had a lone seizure, she stayed up playing Bargain Hunter and other games that must have been mind-numbing to her. In Monopoly, she was always the thimble.  When newFNP was almost fourteen, she came into newFNP's room as newFNP was watching the Iran-Contra hearings -no joke - to let newFNP know that if she ever needed to go on the Pill, she should come to her.  Yeah, thanks Mom, now good-bye.

She smoked Kents and had a butt-ugly yellow robe that she wore every day that newFNP then hated but would kill to have now.  She bought expensive shoes on sale and had clothes in her closet, the hall closet and newFNP's brother's closet.  She wore fancy lingerie because she said it made her feel good.  She framed a painting that newFNP did when she was two and a half and hung it in the dining room, saying that she could have paid thousands for it in a modern art gallery.  It now hangs in newFNP's bedroom.

The day that her aneurysm ruptured, newFNP was waiting for her on the front porch, knowing that she was going to be late for her piano lesson and would get in trouble not only for not having practiced enough, but for her tardiness as well.  NewFNP was mad at her for the latter. It still pains newFNP to think of this.

She had been going to doctors for over a year with headaches before the aneurysm ruptured. She was stoic, however, and never appeared to be in pain, although there were days when she came home from work and had to go straight to bed because of it.  Perhaps her doctors never could have thought....?  NewFNP is keenly aware of this whenever she sees a patient with headache.  

Although absolutely off topic, newFNP wishes that she could share more of her mom with you, but she had only fourteen years with her.  

It wasn't enough.

The return of Cocoa Brown

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

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

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

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

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

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

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

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

Fine.

It was at this point that the power went out.

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

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

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

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

Feliz Cinco de Mayo

NewFNP had completely anticipated a light clinic day today in honor of Cinco de Mayo.  Not so, not so.  Seventy patients in all, 2.5 providers.  

Brisk, right?

On a busy day, why can't all the patients be like newFNP's precocious five-year old who is named after an exotic far-away land and who calls newFNP by her first name whenever she sees her.  

As newFNP turned the corner the other day and saw her in the hall, the little girl screamed "NewFNP!!" and ran towards her - wearing her pediatric paper gown - for a big hug.

"I'm so excited to see you, newFNP!" she exclaimed during the exam room.  NewFNP was intoxicated by her celebrity in the eyes of this little girl.  Granted, newFNP's encounters with this lovely genius are always fun, but newFNP generally only receives this warm a reception when she visits her 92-year old grandma!

Alas, not everyone is so enchanted with newFNP.

NewFNP is ready for a burrito, with salsa verde due to her disfiguring tomato allergy, and a Corona with lime.  Que rico sabor!  

Is 14 hours really enough time to re-group for another work day?  

Five-0

Oh my God, did newFNP ever create one hell of a ruckus at clinic yesterday.

Being a mandated reporter - while important - can be difficult.  Say, for example, when a fourteen year old girl who has run away from home several times and drinks to the point of blacking out and is in newFNP's clinic for a pregnancy test tells newFNP that she doesn't feel safe at home.  And when she says that she is scared of her dad who is, by the way, sitting in the waiting room.  And that she is not scared of him because he is upset with all of her aforementioned behaviors.  And when she finally says that he sexually abuses her.  This four sentence synapsis, by the way, took 40 minutes of listening, questioning, waiting, etc.

So newFNP did what she is supposed to to.  She reported her suspicion for abuse to the local department of children's services who instructed her to call the police.  This is how two, then four, then five, and then seven police officers showed up at newFNP's clinic yesterday.  

If anyone was ever looking for a man in uniform, yesterday was the day to find one.   NewFNP, however, is not in the market.

NewFNP doesn't know if this girl has been abused or if this girl is just incredibly fucked up. Something is not right in her life or she wouldn't be involved in all of the risky behavior she is currently exploring.  It isn't really for newFNP to determine this though - that is for the detectives and the social workers.  

At the end of the day, newFNP cut out 15 minutes early, thinking to herself, "T.G.I. motherfucking F."

newFNP: truant

NewFNP had a whirlwind of a weekend.  

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

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

Friends, it is everything newFNP imagined it could be.  

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

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

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

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

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

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

Keeping it new after all these years

Oh, how newFNP fucked herself by not immediately saying "no way, Jose" to her lorazepam seeking patient.  Blog commentors, newFNP hears you and acknowledges just how correct you all were.  Just when newFNP begins to think that she is no longer so new, something like this happens and newFNP realizes that new has a shitload to do with context.

Of course she came back and of course she wanted more of the sweet, sweet Ativan.  This time, newFNP really did need a prn dose to make it through the encounter.  Instead, she had to rely on her endogenous adrenalin.

Since she had last seen her, newFNP reviewed this patient's former med records which did not elicit the etiology of either the anxiety or the lorazepam prescription.  When newFNP let her patient know this, her patient found this to be an unacceptable obstacle and demanded more pills.  

NewFNP said no.

The encounter was one hundred shades of crazy, but involved soap opera-worthy acting, crying, laughing, the patient telling newFNP that the only reason she returned was that she felt like newFNP treated her with respect during the initial encounter (?!?!) and that she wanted to give newFNP a second chance.  Thanks.  Thanks a million, hon.

NewFNP still doesn't know if she handled this situation correctly, but she does know that if this woman does have a genuine anxiety disorder, Ativan is likely not the optimal choice for primary, long-term treatment and newFNP is not the person to decide what is.  NewFNP would just like you all to imagine what the response was to her offer to complete the psychiatry and counseling referrals.  Good fucking times, my friends.  

NewFNP was mercifully absent from today's all-staff meeting, but her spies expeditiously let her know that the CEO had received some complaints from board members about employees - apparently front desk staff - not treating them well.  Being an FQHC, a percentage of our board members are also our clients. While they say that we are not supposed to treat them any differently, that is a big fat lie.  The take-home message was that we are all supposed to ramp up our customer service.

NewFNP worries that patients like her lorazepam-seeking patient will complain.  She does not want to work in fear of patients who want something that she would be ill-advised to provide. She knows that while some patients are uniformly pleased with her, others are not always satisfied with her service.  The clinic is really not set up for provide great customer service and some of the patients really expect more that newFNP or her colleagues can reasonably provide.  

What to do, what to do.

A little something extra

A huge factor in newFNP's deciding to become an NP was her desire to help people.  This is not unique, of course, but sometimes newFNP gets so bogged down in the B.S. of day-to-day clinical life that she sometimes loses sight of this.  

But then a patient comes in and reminds newFNP why she's there.

NewFNP has a lovely patient who was diagnosed with metastatic choriocarcinoma after presenting to the ED with weakness and a hemoglobin of 3.  After her hospitalization, resection and chemotherapy treatment - which took place at a very fancy-pants hospital - she lost her job of fifteen years and, with it, her health insurance.  She was no longer able to get her regular monitoring at the same hospital.  Because her tumor was hCG-responsive, she needs to have her hCG checked monthly which is how she ended up at newFNP's clinic about a year ago.  

Understandably, when this patient met newFNP, she was also being treated for depression. Cancer, job loss, two young daughters and a precariously employed husband.  Yeah, depression and hopelessness seem reasonable.

NewFNP has seen her several times throughout the year for episodic concerns as well as for her monthly monitoring.  Generally, she has been physically and emotionally healthy.  Today, she finally made it in for her well-woman exam.  Like all of newFNP's patients, this patient worries a lot about money, a concern that has become more salient recently.  Like all of newFNP's patients, this woman needs insurance.  Unlike all of newFNP's patients, she is bilingual and has a social security number and computer skills.  

So newFNP did her pap, listened as she cried and disclosed her concerns about financial woes. She would like to restart her anti-depressants.  She needs her hCG drawn and the result faxed to the fancy hospitals department of gyn-oncology.  She hasn't had the chest x-ray for which newFNP referred her nine months ago because it is just too expensive.

At some point in this encounter, newFNP realized that there has got to be a job somewhere in the five-clinic organization for which newFNP works.  This patient certainly would not be the first to transition from patient to employee - three of newFNP's current MAs were former patients at the clinic!  NewFNP excused herself after completing the exam and asked her clinic manager if he knew of any openings.  In fact, he did.  A brand new clinic was looking for an IPA case manager.  NewFNP brought him into the room and talk to the patient.  

As far as newFNP can see based on an n of one, an IPA case manager works about 50-65% of the time, coordinates fast food restaurant lunch selections 10% of the time, is on the internet 10% of the time and chats with work pals the remaining 15-30% of the time.  There is no way that a forty-something year old cancer survivor cannot do better than that!

Today, this patient left our clinic having received a pap, her regular post-choriocarcinoma monitoring, her mammogram referral, her calcium and physical activity recommendations, and with an application for employment and contact name in hand.  

And she left with a hope and a smile.  

NewFNP knew as she raised the possibility of employment that there was a chance for disappointment.  But sometimes we just have to take chances and, dare newFNP say it, have a little faith.

Rx: vibrator

NewFNP is aware that it is wholly within the boundaries of acceptability to discuss one's sex life with one's provider.  In newFNP's clinic, however, this discussion generally consists of women telling newFNP that they are tired of having sex with their partners and are stupefied at the amount of sex a man wants.  In a 25-patient day, it is exceedingly difficult to suss out if that is because intercourse is physically painful or if it is because their partners are content to sit around and watch TV while the women clean the house & bathe the kids, etc. or if it is because their partners are just sort of remedial when it comes to doing it.

If the aversion stems from physical discomfort, newFNP feels like she can easily manage that discussion.  Not enough lubricant?  Try some Astroglide! 

If the discussion involves a selfish lover/partner, then what is newFNP to do?  There are no Dr. Ruths in newFNP's clinic and there are probably no Dra. Ruths on Telemundo.  Sadly, there is no wonder female sexuality duo a la Berman & Berman. 

But mostly, there is no time.

So what is newFNP to do when her 40-something year old first time patient, all undressed in anticipation for her pap, lets newFNP know that she just never has orgasms.  For all her life, no orgasm.  Sex feels good, but there is just something missing.

And how!!!

Now, newFNP knows that this woman is looking for direction but - hell - newFNP is not her best girlfriend.  She is newFNP!  Can newFNP just say, "Listen.  Seriously listen.  You must teach your man how to perform oral sex.  Period.  At the very least, you guys should watch some Sex and The City reruns for inspiration."

It's a delicate topic, is it not?  How does newFNP know if her patient is open to, say, the cowgirl position or assisted orgasm technology?  They simply do not teach that kind of shit in multiculturalism workshops!

NewFNP didn't say what she may have said to a member of her grad school girl gang, but did bring up some options: communicate with your partner about what feels good; explore for yourself what feels good; maybe try a new position or two; and if all else fails, follow Charlotte York's lead and buy the Rabbit and call it a day.

A very good day.

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.