You down with PCP (yeah, you know me)

It cannot be stressed enough - the 30th patient of the day must not - repeat not - be difficult. That patient could be clinically complicated but personally reasonable or that patient could have a "gimme" diagnosis. NewFNP's favorite is UTI, but she could go for an otitis media or a fungal derm as well.

NewFNP isn't sure how to triage for this when scheduling appointments, but if she could develop an algorithm for optimal patient scheduling that ruled out end of day challenges, she could retire and buy an S4 and some Tory Burch tunics.

As newFNP perused patient #30's chart before entering the room at 4:40 to begin said patient's complete physical, she noted that another provider had charted "PCP abuse."

PCP? NewFNP glanced at her watch. She had not, in fact, used her flux capacitor and time travelled back to 1983. It was firmly 2009. She imagined that the demand for PCP would be minimal and that this patient's dealer might have a 2-for-1 special or a sign that screamed, "PCP - no waiting!!" whereas the lines for meth and crack would loop around the block. Of course, truly, newFNP has no frigging idea about PCP procurement. And even more significantly, she has no idea about PCP addiction treatment.

So newFNP goes about the social and medical histories which, as one might imagine, were both colorful and sad, and got around to asking about the PCP. She had been smoking PCP on and off for over 20 years.

"When was the last time you used PCP?" newFNP asked?

"Well, it stays in your system for a long time," #30 replied.

Hmmmm. It's an answer, yes, but it's an answer to an entirely different question.

"Oh, OK," newFNP responded. "So about how long ago was the last time you used PCP?"

"I want to stop," #30 replied. "It's hard to be a mom."

NewFNP imagines that it is hard to be a mom and that anyone would want to stop PCP use. Still, that nagging little question was stuck in newFNP's craw. NewFNP acknowledged her patient's desire to stop and assured her that she would receive a referral to behavioral health/addiction medicine treatment. But she had to ask.

"I'm sorry but I'm still unclear as to the last time you used PCP," newFNP gently prodded.

"I told you already!" #30 exclaimed.

"I don't think you did," newFNP stated. "You told me that you wanted to stop and that PCP stays in your system for quite some time. But I don't know how long ago you used."

"A month ago," she stated, as easy as 1-2-3.

The thing about PCP is that its lore is full of horror stories - people thinking they can fly while intoxicated, people exhibiting superhuman strength, people having delusions and behaving violently. And it's an hallucinogen, a class of drugs for which there is a paucity of documented treatment modalities.

So, after a month of not using in the face of all the same life stressors as are always there, how does someone maintain abstinence?

NewFNP gave her a counseling referral and some encouragement, but that's not really enough. Unfortunately, it's all many primary care providers have to give. Mental health and addiction treatments are expensive and not adequately covered under insurance plans and certainly not under this woman's public insurance plan.

Maybe newFNP should refer people to Intervention - let Jeff or Candy give it a whirl.

Rack 'em up

NewFNP is back from her conference and - you know - nothing says 'welcome home' like a diagnostic mammogram!  As she prepared for her appointment and dutifully neglected to deoderize and moisturize, she reminded herself not to worry until there was something to worry about.  She arrived at her fancy-pants medical center, registered, donned the wristband and was called back to get changed.

She changed into her seersucker gown in the mammography center dressing room and glanced at herself in the full-length on her way out.  The mammo-gown was actually flattering.  They must have had DVF design the fucking thing.

Having never had a screening mammogram, newFNP is not quite certain as to the extent of its torture but she will say this: the diagnostic mammo is no way to get initiated into the world of breast imaging.  Eight views - none pleasant.  

NewFNP didn't realize that, in addition to the breast tissue, the mammography technician would need to manipulate her xiphoid process into the images.  

When her sweet as could be technician finally got newFNP's breast flattened so as to resemble a fucking crepe, she - in all seriousness - told newFNP not to move.

"Honey, I wouldn't dream of it," newFNP responded.  After all, newFNP rather likes having two generally symmetrical breasts and felt quite certain that any attempt at escape would be a) futile and b) mutilating.  

Although newFNP made light of her situation with her technician, she couldn't help but to feel a twinge of worry.  Her face must have betrayed her worry and a kind lady in the waiting room commented on what a horrible waiting room we were in. 

NewFNP agreed.  The woman told her that she had her first mammography at 37 and that her mother had died at a young age from breast cancer.  She went on to say that she had had "a thing" removed a few years ago.  It was benign.

"I have a thing," newFNP told her.  Although newFNP knows it is benign, it felt oddly good to unburden herself to this lovely and kind stranger.

"You do not worry until there is something to worry about," the woman told newFNP, echoing her very own thought.  "That is not denial," she said as we stood together to schedule our next appointments - hers in one year, newFNP's in two days for ultrasound.

(NewFNP made the follow-up appointment, but could not help but to think that she is caught in the middle of a CYA-medicine spiral.  Is the fine needle biopsy next?)

NewFNP and this woman finished their boob and metal sandwiches at the same time and walked down to the valet together.  As the valet drove her car around, newFNP commented that we have the exact same car.

"It was meant to be," she said and gave newFNP a caring smile that made her believe it was true.  

 

Taking it (the Big) Easy

The last time newFNP was in New Orleans, she was 22, on a meandering cross country road trip which had such highlights as the Carlsbad Caverns, Graceland and a variety of Shoney's restaurants, and was bunking in a bright pink hotel called The Frenchmen.  

This time she is at a conference - an addiction medicine conference - at the Hilton.  

Note to the addiction medicine conference organizers: there is a W just a block away.  Think about it.

Anyway, the highlight of the conference so far may be the following patient quote shared with the audience of listeners at a lecture about stimulant use and hypersexual behavior.  The patient, noting his inextricable link between buckwild sex and cocaine use lamented, "I guess I'll just have to get used to sex without the hookers and the drugs." 

The quote is funny, but newFNP acknowledges that is problem is, of course, not.

NewFNP did make a quick afternoon escape from addiction to see a super great/creepy exhibit at the Audubon Insectarium and to sample some local cuisine: she had fried alligator (and a salad) for lunch.  

Yum.

Not so lovely lady lumps

It's been a long time since newFNP has been on the business end of a cytobrush.  A year, in fact.  But today was the day for newFNP to go from provider to patient and shimmy down the table into the stirrups for her annual exam.

When newFNP was in training, it was one of her articulated goals to perform the pap well, with the least amount of discomfort possible.  NewFNP has achieved that goal.  Her patient frequently tell her that they barely felt a thing - it makes newFNP so proud.  

In order to achieve her gingerly executed pap exams, newFNP uses the cervical spatula and mascara wand combo and performs 1/2 - 1 turn of each.  She goes from 12 o'clock to 6 o'clock with the spatula and makes a turn with the brush adequate to touch on most areas of a parous cervix.   If she sees an area of suspected abnormality, she gives that a swipe as well.  Throughout the process, she uses a light touch.

NewFNP's OB/GYN, on the other hand, uses the broom cytobrush, aka the cervical pitchfork, and makes about 75,000 full-force turns with that SOB.  She clearly does not believe in the light touch and her "a little cramping here" warning is an understatement indeed.  But fine.  It last for six seconds and is over.

What is not over is the wait for newFNP's diagnostic mammogram.

NewFNP is certain that whatever is embedded her breast tissue is a fibroadenoma.  She is certain that it is not cancer.  But now she has to have a boob and metal sandwich because the seed of doubt has been planted and her OB/GYN encouraged her to get that frigging thing done without delay.  And she's kind of pissed because of course it will be nothing yet she will have had to have her never-lactated, full-density breast all squished up in order to have the reassurance.

Ouch.

And nothing makes a lady feel old - prematurely old - like having a goddamned mammogram.  

The world is your oyster

When newFNP decided to become an NP, it was really because she wanted to take care of patients in a community health setting.

Done.  

So when that gig burned her out, she looked around to see what else was out there.  Her research position just happened to be waiting for her.  Serendipity.

So now newFNP alternates between mellow, organized, important work days and hectic, clusterfucked, important work days.  It's pretty cool.

And that is a pretty cool part of being a health care professional.  

We have options.

Both positions have their positive aspects and their negative aspects.  

At the community clinic, newFNP practices independently.  She is an authority on certain aspects of care.  She makes connections with patients and nurtures those connection as best she can.  Yet she is expected to see 30 patients daily.  Her patients wait hours to see her.  And did she mention already the utter clusterfuck in regards to organization (or a lack thereof)?

At the research clinic, newFNP is really, truly treated well by her supervisor.  She has more than adequate time with each of the research participants.  She is learning about conducting research in an academic environment in which doing things correctly is the respected and expected modus operandi.  She is learning a lot about drug addiction and is appreciating the importance of discovering new treatments for it as she meets with and learns about her patients and their lives.  And there is a crazy delicious burrito stand mere footsteps away.  Yet she makes no independent decisions, which, for newFNP is kind of a drag.  That's the only real downside.  Perhaps that will come in time.

As soon to be NP grads are hitting the job market, newFNP would offer this speck of advice:  take the tough job first.  Work in an environment that challenges you to become a better, more skilled provider.  Learn.  Sweat.  Make mistakes.  And, after a few years, look around and see what is out there.

Fashion disaster

NewFNP long ago gave up her white coat.  Too stuffy.  Too many cheaply sewn buttons falling off and too little desire to mend.  Too much unflattering hip-spread look.  Plus, it spent quite a while in the cargo area cum unwanted goods graveyard of her car and newFNP kind of just forgot about it.  She now just rocks whatever outfit she's rocking that day and, for the most part, it's all good.

Imagine, then, newFNP's chagrin when she finished a pelvic exam and noticed that her right sleeve felt a little heavy as she exited the room.

She glanced down and noted a big glob of speculum jelly adorning the sleeve of her crisp celery-colored J. Crew cashmere sweater.

Son.  Of.  A.  Bitch.

Quickly and with a slight shudder, newFNP shut down the horrifying thoughts racing through her mind and told herself, again and again, that the speculum jelly now seeping through the soft cashmere yarn and quite possibly tickling her silky smooth wrist skin was, in fact, sterile.  It was leftover jelly from the tray which newFNP uses to lubricate the speculum, not jelly from the used speculum itself.  

It was from the tray.  It was tray jelly.  Not speculum jelly.  Tray jelly.

No matter the source, newFNP was none too keen on having jelly on her cashmere.  She washed it off, scrubbed off her wrist and - with it - her morning dab Fresh 'Sugar' fragrance, rolled up her sleeves and went about her day.  

 

A sweet rack

Dude.

NewFNP is totally cool with mental health days.  Go to the Korean Day Spa for a naked lady Rub-n-Scrub and shed that nasty dead skin!  Go see I Love You, Man and eat a large popcorn.  Sleep.  Whatever.  

But do not be newFNP's MA and call in sick when you are, in fact, getting new boobs.  

Sure, go ahead and get your new knockers.  Whatever.  Your life is hard.  Your soon-to-be-ex-husband is a dick.  NewFNP understand the urge to make a change when a relationship ends.  But take a day and get a frigging facial, a hair-do and some airbrushed Coach nails.  

But when you are having cosmetic surgery, you should take a vacation day (or seven).   You should not be the employee that burdens her colleagues for boobs.   And just how much is newFNP's clinic paying these MA's, for the love of God, if they are taking sick days for rack enhancement?!!

Honestly, newFNP just does not understand the desire for two inflated saline balloons in one's chest.  Just get some boob cutlets and a push-up bra and call it a day.  Total cost - fifty bucks.  Less if you hit up the semi-annual sale at VS.

But even more of a bummer is that newFNP has really felt like this employee was committed to the team and understood the importance of her role.  

And that changed today.  Possibly even as much as her MA's new cup size.

Bring it.

There are times in everyone's role transition in which they wonder if they are, in fact, cut out for the career they chose.

NewFNP had several such instances in which she thought - whoa pal... perhaps law school.

The first involved a patient who had a horrendous necrotic pressure sore that was so deep, it almost exposed the bone.  This woman also had MRSA which meant that all staff were on contact precautions which, in newFNP's training hospital, consisted of a mask, gloves and a plastic gown.  

It was the end of the day's rotation and newFNP had been busy as hell.  She hadn't eaten.  She was tired.  And the smell of that pressure sore plus the tenting of the skin as the physician cut away necrotic tissue plus newFNP's hunger plus the millions of people in the room causing increased temps (and smell) plus the plastic precautions gown equaled newFNP sitting on the floor with her head between her knees in an attempt not to pass out.

A successful attempt, but clearly not a shining moment in student nursing history.  

Another involved a patient who had undergone a partial pneumonectomy and, for reasons that now escape newFNP's memory, had failed to heal well.  As a result, he had what is best described as a gill-like slit in his side that moved in a gill-like fashion when he breathed.  And in that gill-like slit, there were strings of mucous that would quiver during respiration.  

The vivid recollection sends cold shivers down newFNP's spine.  

NewFNP left the room and told her preceptor, "I don't think I'm cut out to be a nurse" to which her preceptor raised one eyebrow - her way of saying that she disagreed.

NewFNP wrote about another unsatisfying olfactory experience three years ago.  NewFNP recalls feeling so disheartened.  How on earth would she take care of her patients if she could not even observe this procedure and remain on her feet? she wondered.  NewFNP's consulting physician attempted to console her by confirming that that was, in fact, a hella smelly abscess but it didn't really make newFNP feel much better.

NewFNP has come a long way, baby.  In these past three and a half years, newFNP has incised and drained her fair share of abscesses, but for the past year, the abscesses had dried up.  

Until today.

When newFNP hasn't performed a procedure in a while, she feels a tad apprehensive prior to embarking upon one.  Especially when it involves a scalpel and lidocaine and inflicting pain.  But the beauty of having a few years under one's belt is that it all comes back to you when you need it.  For better or for worse, even the inflicting pain becomes easier in one of those you've got to be cruel to be kind kind of ways.

And - gross though they may be - procedures are kind of fun.  They are so much better to perform than to observe.  In the case of an abscess, the results are immediate.  The smell doesn't seem to bother newFNP so much when she is doing the cutting, expressing, irrigating and packing.  

In fact, she wonders how her MAs are such tough asses in their assisting whereas newFNP has near syncopal episodes.

NewFNP is ready for more!  

Again, for those struggling students out there, it's worth it.  You'll be ready, too.

Money honey

NewFNP has read article after article lamenting the primary care physician shortage.  Often times, this is attributed to the high cost of medical school education. It's true - med school is expensive.  It's true - physicians can make more money in specialty practice.  

Nonetheless, these articles make newFNP a little pissy.

Jut hold up, mofos.  There are nurse practitioners out there who are thrilled to be primary care providers.  Nay, they chose to be NPs because they wanted to provide primary care.  They wanted to prevent illness, they wanted to treat the whole person and not the disease.  They wanted to be part of a health care team.  They wanted to judiciously refer to specialty when the situation necessitated the referral.  

And guess what?  They have debt.  They may even have a shitload of debt.

NewFNP's fancy NP school was seven semesters in length.  The total tuition cost was in the neighborhood of $98,000.  That's just the tuition.  That's no rent, no books, no required health insurance, no specific-colored scrubs so as to identify students as students, no RN license.  That's no red wine, no haircuts, no used book cafe coffee & treats with one's lady friends.  And, at newFNP's school, there were a fair number of us who had other graduate degrees and their associated student loans.  Thank heavens for the in-school deferment!

And thank heavens for loan repayment which mercifully wiped out quite a chunk of newFNP's debt, which now totals just a smidge over $60,000.  Ah - $60,000 - it seems so reasonable.

So what is newFNP saying?  She's simply saying: yo -- NPs!  She feels your pain.  You work hard, you take good care of your patients, you pay your six-figure student loan debt.  Keep it up.  

And for those of you in fancy and pricey NP schools, it's worth it.  It's totally frigging worth it.

Hard times

NewFNP noted recently that the economy is really hurting her patients.  

It's worse now.  

NewFNP referred three adult men and one pregnant women to food banks this week.  Adult men in newFNP's clinic, as a rule, are a stoic bunch.  They do not tell you that they are hurting or sad or worried.  This week, newFNP saw desperation and fear in her patients' eyes - worries that they will not be able to feed their families, let alone pay their rent.  

NewFNP hears on the news that lines for food assistance are longer, she hears the monthly unemployment numbers.  She wonders if robbery is increasing as people become more desperate.  Will the incidence of domestic violence increase?

During the Great Depression, unemployment rates were around 25%.  In newFNP's county, they were almost 11% in January, a 3% increase since September.  In newFNP's service area, unemployment is between 12-19%, depending on the zip code.

If you live in the hood, this is a depression.  It is a depression.  NewFNP's 401k is going through a recession but she has food on the table and gas in the car and not one but three paying jobs.  

NewFNP is acutely aware between the haves (her) and the have-nots (her patients) as she sits in the exam rooms, listens to their stories and provide them with the best care she can given that the answer to their worries lies outside of the exam room walls.  

On a lighter note, the aggressive-statement-maternity T-shirt shop does not appear to be struggling at all.  NewFNP's non-fronting pregnant teen showed up to clinic this week wearing a shirt telling everyone to STOP HATIN.  The graphic was, of course, a faded stop sign.

Oh give me a home

If you are looking for a medical home, pal, newFNP's clinic ain't it.

Truly, in no way does newFNP's ramshackle community health clinic meet the criteria for a medical home.  Access to one's regular provider* and a personal relationship with this person?  No.  Evidence based practice and support for providers?  Nope.  Expanded access to one's primary provider via phone or email?  Sorry, no.  Comprehensive care?  Yeah - no.  Reasonable wait times?  Ha!  That might be the most blatant 'no' of all.

Jesus, newFNP is a little bummed just thinking of all the ways in which her clinic sucks.  

When newFNP thought of how she wanted to impact the well-being of the urban poor, she thought that she would help her patients to achieve health and thereby the ability to work given that they are - you know - not having MIs and diabetic retinopathy and teenage pregnancies.  In her obviously skewed and possibly delusional pre-community health clinic mindset, access to healthcare led to health which led to well-being which led to productivity which led to the promise of financial stability and a brighter future for themselves and their families.

Ha!  What the hell??!?  Where has that wide-eyed girl gone?  It's hard for newFNP to imagine herself being so idealistic.

There are times in which newFNP wonders exactly what good she is doing when her patients wait five hours to see her for a follow-up visit.  

As newFNP has mentioned, her days have become busier since pulling back on her clinical hours.  During this transition, newFNP has noticed a change.  Her patients are waiting to see her despite the ridiculously long wait.  

They come to clinic on newFNP's assigned days and wait.  When they are assigned to other providers on a given day, they advocate for themselves and assert that they will wait rather than being cared for by someone whom they do not know.  Of course, this is normal and the ideal situation - patients should not have to explain their diagnoses and personal situations over and over again.  But newFNP just loves that these patients dig in their heels and say no.

They are medical homesteaders.

If newFNP was running the show, she would make one small change that might decrease the wait times for her loyal patients - and all of her other patients as well.  She would schedule her patients on her actual schedule.  

Seriously people, where is newFNP working?  In a fucking MASH tent? Her clinic does not even schedule patients using newFNP's schedule template, yet newFNP sees 25+ patients every day she works.  Does that make sense?  If so, someone please drop some knowledge on newFNP because she would love to know.

----------

* The literature about medical homes all use physicians as the team leader.  While newFNP appreciates the importance of physicians in the medical team, she does not believe that physicians need to be the primary care provider with whom patients have a relationship.  NewFNP is not about 'us vs. them' but rather believes that there is room at the table for everyone.  As the old saying goes, there is no "bite me" in teamwork.  Or something like that.

On the OB front

NewFNP's practice includes routine, low-risk office obstetrics. In some ways, it's a really nice practice - moms, babies - what's not to like??

Unlike other offices, newFNP's clinic does not have on-site ultrasound. Nor does her site have a family practice MD, an OB/GYN or a certified nurse midwife. Therefore, when newFNP runs up against a concerning finding, she has a few options. She can call the family practice MD at another site, she can consult with Dr. Dual-Ivy-League-Degrees who has some ER OB experience, she can page an attending OB at a nearby hospital or she can call BostonCNM for a telephone consult.

NewFNP wasn't expecting anything unusual with her 37-week primip yesterday. Sure, she was wearing a t-shirt with the phrase "OTHER BITCHES JUST FRONT" emblazoned across her chest in red 200-point font, but other than that, nothing out of the ordinary.

(As an aside, what does that even mean? Does it mean that she is a bitch, but that she in no way fronts? And if she is 100% not fronting, to what does that even refer? NewFNP is very confused.)

As newFNP starting asking her routine prenatal care questions, it came to light that her patient had been seen in the ER for preterm labor a mere six days before. Of course, she did not go to the ER where she is registered nor did she bring paperwork detailing the visit. According to her, she did not receive medications to stop the contractions, she had a normal NST, was observed overnight and then released. She had her paperwork at home, she assured newFNP, and would bring it to her next office visit.

NewFNP proceeded with the exam and was startled when she auscultated distinctly irregular fetal heart tones.

"Why they sound like that," her patient asked. "They was like that in the hospital too."

"What did the doctor say," asked newFNP.

"I dunno. He said it's normal I think," she replied.

Great. Sure, it can be normal. It can be a totally benign finding. Her 24-week level II ultrasound was normal in every way. But a repeat ultrasound or a fetal echocardiogram would provide newFNP with the reassurance she so sorely lacked at that moment.

NewFNP filled out the referral form for a perinatology consult and a repeat ultrasound.

When it comes to prenatal care, newFNP does not front. Whatever that means.

You shouldn't have!

NewFNP isn't one to buy gifts off the street.  Maybe in Milan or Oaxaca, but not so much in her clinic's urban area.  However, judging by the amount of temporary vendors that pop up around the holidays - real or created - the urban stuffed animal street gift economy isn't suffering too much.

In fact, there are all manners of crappy gifts to be purchased streetside!  NewFNP's interest in the street gifts was piqued when she noticed a trend, some may say disturbing, several years ago around Mother's Day.  The hot ticket item that year was a ceramic swan in one's choice of ladylike pastels with a faux flower arrangement sprouting from the swan's hollow back.  

No swans for Valentine's Day 2009.  No sir.  Of course, there are many options for Winnie the Pooh stuffed animals - small and large and extra large - wrapped in clear cellophane.  There are carnations and roses and mini balloons.  All of these things are available, sure, but are they really special?  Is the mini Pooh with carnation combo really going to say "I love you" and possibly lead to mind-blowing amour on this potentially amour-filled day?

Or is a four-foot tall mirror in the shape of Tinkerbell going to nail it?  Because if it is, newFNP knows where to score one.

Now, it might be said that newFNP's tastes tend toward the finer things and often exceed her budget.  Her current obsession is the Bertoia bird chair (and ottoman) and the Tiffany & Co. platinum and diamond anchor pendant.  

Alas, newFNP is not holding her breath.  

Happy V.D. everybody!

Damned if you do

NewFNP feels pretty confident about her diabetes management, her hypertensive skills, her strep throats and all the day to day family practice stuff.

But where newFNP gets a little tripped up is with the more uncommon diagnoses, such as Myasthenia Gravis, a pretty horrible autoimmune disorder in which your body creates antibodies that block its acetylcholine receptors, thus causing muscle weakness.  A gross oversimplification, but it's late and newFNP needs to get out her physiology book to really explain this any better.  End result is weakness because bodies need acetylcholine for muscle contraction.

Anyway, some people have ptosis - or weakness causing eyelid droop.  Others have generalized weakness which frequently causes weakness and fatigue with chewing (a bulbar symptom), neck weakness that can lead to head droop and limb weakness.  Still others have respiratory muscle weakness which can necessitate intubation.  Not so fun.

NewFNP's patient has the generalized, bulbar weakness kind of myasthenia.  She had a thymectomy about a year ago.  It didn't help too much.  She saw her neurologist a few weeks ago and was told to increase her aceylcholinesterase inhibitor - Mestinon - as well as her immunomodulator - prednisone.  She is taking 8-10 tabs of Mestinon daily, as well as 8-12 tabs of prednisone 10mg - a hefty dose indeed.  And her jaw continues to fatigue with chewing.

Because she was worried about her nutrition, she supplemented her diet with Ensure.  Five to six Ensures a day for the past month, in fact.  According to the Ensure website, each Ensure has 350 calories and 22g of sugar.  And because everyone needs a little treat every now and then, she had been indulging in QID mini-doughnuts for about a week or so.  

Anyone who has ever taken prednisone in the past knows that it can make you hungry, even ravenous.  It can also in and of itself tip a heavy prednisone user into steroid-induced diabetes.  Combine that with 1750 kcal/day in Ensure alone and you end up with a random glucose of 236 when you present to your well woman exam.

Frankly, newFNP was surprised that her sugar wasn't higher.  Twice normal is so pedestrian in her clinic!

So then what do you do if you are newFNP?  NewFNP cannot just take the patient off of her prednisone and start her on something else - that is neurology's purview.  She can, and did, encourage her patient to chill out on the Ensure and doughnuts, to call her neurologist and let him know that her sugar is high, and to start taking Metformin.  

Did newFNP mention that this patient is also depressed and was previously abused by her partner?  Then she was diagnosed with myasthenia and had a thymectomy.  And now she has diabetes.  

The whole situation sucks.  

It's the economy, stupid!

Beginning a few months ago, newFNP noticed a disheartening trend.  Many more of her patients - young, generally healthy patients - were coming with in complaints of things like dizziness, tingling in the arms and fingers, headache and diffuse muscle pain or, as a colleague likes to call it - total body dolor.  NewFNP recognizes these symptoms as depressed mood.  As newFNP is not a fan of the don't ask, don't tell policy in regards to a few things, including the medical history, she attempts to suss out the true cause of these symptoms.  Her patients appear relieved that someone is actually asking them about the quality of their lives.  Generally, they had experienced months of financial stress including food insecurity, home loss or inability to pay rent and zero prospects for imminent improvement.  

When newFNP asks the questions about life stress, the question is often answered in a deluge of tears, seemingly pent up for all these months - perhaps trying to keep a strong face in front of the kids or family but unburdened in the small exam room.

Do these people need medical care, per se?  No.  What they need are jobs.  It makes newFNP wonder about how bad things really were in the countries from where her patients came.  They must have been awful to risk moving illegally to the US, to move to impoverished areas where their children often flounder - for a variety of reasons - in school or are introduced to gangs and to where supply greatly exceeds demand for unskilled laborers.

NewFNP did not go into healthcare to make the big bucks.  But the truth is, she's OK financially.  The only change in newFNP's life is that her clinical hours are busier than ever before and her 401k balance is dismal.  What a relief that newFNP has decades of work ahead of her to recoup those losses!  Decades of work.  Fuck.

Anyway, newFNP supposes the real question is: what has this multi-multi-multi-billion dollar bailout done for the average middle-class person, the working class, the poor?  NewFNP knows that AIG executives are doing fine, but her patients aren't and neither are many families across the country.  We need a TARP for real people, a new New Deal.  How about more student loan debt relief for teachers, nurses, physicians?  How about actually giving money to taxpayers to pay they mortgages and student loans to the banks, who will then not have to ask for a bailout?  How about putting a TARP over impoverished communities to bring better options for disenfranchised youth?  To parents who want to work?

And now the Republicans don't want to pass the current stimulus package because there is, among other things, money for contraception??  What the fuck?  People who can control their fertility tend to be more productive.  People who work in clinics where contraception is a part of care earn money and pay taxes and mortgages and credit card bills.  

NewFNP swears to God, enough is enough.  

A new beginning

Should today not have been a national holiday?  Should we as a nation not rest for one day every four years to honor ourselves and our President?

NewFNP did pause today.  She sat on the floor of the standing room only waiting room with a precocious five-year old African-American patient in her lap, her five-year old scrawny arms draped around newFNP's neck so that she and newFNP were watching the oath of office cheek to cheek.

"Do you know what today is?" newFNP asked this little girl, M as Vice President Biden exited the podium.

"No - what?" M replied.

"Today is a very special day.  We are getting a new president - our first black president," newFNP told her.

"Obama?!?" she exclaimed, wide-eyed, although she pronounced his name Obommer.  "I like Obommer!"

"So do I," newFNP said, giving M a big squeeze.  "So do I."

Make it a double

It is no surprise to newFNP that STDs are on the rise.  Hell - in newFNP's clinic alone, she had several cases this week!  Gonorrhea, check.  Chlamydia, check.  And repeat.

NewFNP's approach to disclosure of STDs is straightforward.  It is generally something along the lines of: newFNP called you in today because your test results came back positive for chlamydia.  NewFNP then pauses so as to gauge the individual patient's response.  Some people are very nonchalant when they hear the news as though it was only a matter of time.  Some people are angry.  Still others are shocked.

Then there are responses such as this: But she told me that she was a virgin.

Well, maybe she wasn't.  Maybe you were infected asymptomatically and here we are finding out right now.  NewFNP doesn't spend a hell of a lot of time conducting an epidemiological survey.  She treats her patient and, for chlamydia, she dispenses treatment to take to the patient's partner(s).

NewFNP brought her patient some water, his Azithromycin, as well as his partner's treatment dose.  He took his medicine, set down the cup and tapped the partner's bottle.  

"Uh, can I get two of these?" he asked sheepishly.  

Sure buddy.  Two partner treatment doses it is.  Trying to blame it on the ex-virgin.  Indeed!

Oh-ooh say IUD!

It has been a long time since newFNP donned her protective gown and suited up for the old IUD insertion.  So when her awesome MA told her that her G2P2 with 2 c-sections was in for a placement, newFNP was a little nervous.  A nullip cervix after all these months of an IUD insertion-free existence?  

"Not to worry, newFNP," her MA said," she's menstruating."  And it's day two and it is a-flowin!

So newFNP got her patient prepped in the all-revered lithotomy position, placed the speculum, swabbed the moderate blood to better visualize her work place, and placed the tenaculum at ten and two o'clock.  Click!  Things were moving along super smoothly as newFNP quite easily sounded her patient's uterus to a respectable 9cm.  

As newFNP was adjusting her vadge light to confirm that 9cm was in fact the magic number, a very, very unfortunate event occurred.

During the light adjustment, newFNP made the rookie mistake of not having one hand on the speculum.  You see, newFNP's clinic does not have the fancy light-equipped specula.  It has the old school cumbersome swan-necked style lights.  One hand on the sound, another on the light and a setback occurred.  It was just a seconds-long oversight that led to a size-medium bloody speculum to fly out of this lady's lady business, only to be caught by the still-in-place tenaculum.

Shit!!

NewFNP quickly and blindly removed the uterine sound as her sympathetic nervous system did an auto-reboot.  She then paused for a millisecond to control her blood pressure as her patient and MA laughed the experience off.  Thank God newFNP had done this patient's entire prenatal care course as well as her post-partum and well-baby care, and was known to her patient as not being a total frigging schmuck of a provider.

NewFNP replaced the speculum with the tenaculum still in place, a feat not so easily accomplished - you'll just have to trust newFNP on this one.  She then pulled her other MA into the room for another hand to assist with speculum position maintenance throughout the remainder of the procedure which was as seamless as could be.

Perhaps newFNP should dig up her old chemistry goggles for her future IUD placements.  

Thirty five

NewFNP asked for it.  

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

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

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

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

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

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

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

Weird.

Bust a capful

It is not so often that newFNP has one of those "I've never heard that before" moments.  And perhaps a vaginal exam is not the preferable circumstance in which to experience said moment.

NewFNP's patient was gravely concerned that her purportedly well endowed partner had somehow maneuvered her IUD out of position and that she was, therefore, pregnant.  NewFNP had already seen the negative pregnancy test in the chart, delivered the result to the patient and offered to do a quick check to reassure her patient that the IUD was, in fact, intrauterine in location.  

Although she consented to the exam, newFNP's patient specifically requested the use of a small speculum, which seems rather ironic given the reason for her aforementioned concern.

"A small speculum?" questioned newFNP.

"Yes," she replied, "because I use a capful."  The way in which she casually said this assumed that newFNP was in the know regarding the significance of a capful, as though the use of a capful was a secret shared amongst women across the land.

"A capful?" newFNP inquired.

"Yeah, you know, a capful of vinegar," she explained.

NewFNP puzzled expression must have clued her patient in that she was not at all following.

"To keep it tight," she explained, "I put a capful of vinegar in my bathwater and that keeps you tight."

Does it now?

Vinegar.  To dye easter eggs?  Yes.  To clean one's linoleum?  Sure.  To freshen one's coffee pot after a year of French Roast brewing?  OK.  But to keep a vagina tight?  NewFNP is quite sure that Heloise would not offer that as a hint for non-food-based vinegar use.

NewFNP recommended Kegels, confirmed the IUD placement, reassured her patient of both her non-pregnant and actively contracepting status, and went on her vinegar free way.  

Sticks and Stones

NewFNP's clinic is breaking an unspoken mid-to-late December rule: keep it slow.  Get out to the dollar store for some inexpensive winter-wear or to the champurrado vendor for some must-be-an-acquired-taste thick, greasy, masa-based hot chocolate but let newFNP have some holiday peace.  

But no!  NewFNP's productivity is through the frigging roof!  She is averaging 30 patients per day and she has a student to boot.

A sub-par student.

There are some students who are great, like her NP student who attends newFNP's alma mater, like her PA student who was a former army medic and saved newFNP's ass as she incised and drained the biggest ass abscess she has ever seen.  

Her current student is not good.  She's not good.  And she called newFNP "sweetie."  Not once, but twice in the few weeks she has been there.  NewFNP hates that kind of shit.  She's no sweetie, mother-effers.  And she is not B.F.F. with this young woman.  However, newFNP has been so damned busy that she hasn't had the opportunity to nip that shit in the bud.  

Sweetie?!?!!  Ugh.  It's repulsive.

12/21/08 update: In her defense, newFNP's student definitely does not think that she knows everything and she writes everything down.  But her history taking and her SOAP notes are not so good and newFNP is a stickler for a good history and note - it makes everyone's life easier as patients come back for subsequent care.  And then there is the issue of the 'sweetie' thing - is she taking her rotation seriously or is she looking to ingratiate herself?  In newFNP's eyes, the easiest way to a fond feeling is a great performance.  

Violence

NewFNP regularly screens her patients for intimate partner violence (IPV).  It's just one question, usually either "Do you feel safe at home?" or the not so nuanced "Does your partner abuse you?"  It is a hard question to ask, but it becomes less hard the more you ask it and more hard when the answer is yes.

When the answer is yes and you work in a super ridiculous community health center, your day will be sub-par but likely nowhere near as crappy a day as the days leading up to a patient's disclosure that the are abused by their partner.

NewFNP's responses have been varied - she has sat with a patient while the patient called a local hotline, she has referred a patient to our fledgling medical-legal partnership, she has called the police.  

But yesterday, a patient for whom the answer has been 'no' came in and disclosed that, all this time, the answer has in fact been 'yes.'  At some point, this woman had the wherewithal to obtain a restraining order.  This may have been when the abuse extended beyond her and to her oldest child.  

Like many women, she wanted her partner to change.  She wanted the abuse to stop, but she didn't necessarily want the entire relationship to stop.  Like many women, she was afraid of losing her children - a fear heightened by her partner telling her that this was, in fact, what would happen and by her complete detachment from the legal system.  

In some ways, this was an easy decision.  Children are at risk, he violated a restraining order.  NewFNP dialed the police.  Unfortunately, he had left the house by the time they arrived.  

When newFNP was in public health school, she visited a women's prison as a part of a class on family and sexual violence.  It was a life-changing experience.  In that group of women - convicted murderers - there were PTA moms and biker ladies.  There was a woman who killed the man who got her daughter strung out on drugs and abused her.  There was the woman who, after a brutal beating, killed her husband while he slept because he had been threatening to kill her and she knew that he wasn't kidding.  Mostly these women were serving life sentences. 

There are more aspects to this crime - on the batterer's side and the abused partner's side - than newFNP knows.  Issues of power, of fear, of control, of rage, of money and poverty, of fucked up childhoods, of desperation, of gender inequality, of protecting what is valuable to you.  

But these women shouldn't be locked away for life and newFNP's patient should never be in a position so desperate that homicide seems the only solution.

So ask.  Just ask.  As a provider, you might not have all the answers, but you are sure as hell equipped to find them out for a patient who might be caught between the bat and the belt.  Or the gun.  

This little piggy stayed the hell home!

It's getting to be the holiday season and newFNP is sure that, like herself, there are many ladies who would like to get spiffed up for the festivities.

In order to be spiff and shiny, newFNP ordered herself some Kama Ayurveda Miraculous Beauty Fluid (an ayurvedic treasure) and some Lippman Collection Bitches Brew nail lacquer.   Highlights aside, newFNP is a practitioner of DIY beauty.  And though newFNP is loyal to her Retin-A for its utilitarian anti-aging/anti-acne benefits, she is a big lover of the rich, luscious facial serum.

You see, newFNP wants to look pretty pretty, but she does not want to spend tons of dough on comedone extractions and she does not want to go to the nail salon.  And why?  For one, in the world of beauty treatments, isn't a mani-pedi a bit of a rip off?  Especially a manicure - if you are washing your hands all damned day, that $20 mani is shot to hell by patient number 7.  For two, newFNP is super ticklish.  For others, a pedicure is an exercise in relaxation.  For newFNP, it's something that the CIA used to ban.  

But even more importantly, newFNP is simply fearful of having toenail fungus.  When she is 70 years old and her eyes are so bad that she can no longer see her long lady toes, fine.  Toenail fungus it is.  But newFNP is not giving up just yet.

NewFNP sees a lot of funky feet at work.  She overcame her hesitation of peering for areas of maceration between moist toes, freed of their sweaty poly-blend socks and work shoes.  She regularly assesses the dorsalis pedis pulses and is only mildly skeeved by the moist warmth of foot flesh.  

And everyone has onychomycosis.  The odds of finding a full set of normal toenails is somewhere in the ballpark of the odds of winning the Powerball.

Furthermore, newFNP remains scarred by her experience as a young public health professional when an epidemic of cutaneous tuberculosis was traced to a local nail salon and their recirculated water bowls.  Not good.  Not pretty.  Not healthy.  

So for this holiday season, newFNP recommends stocking up on your own favorite beauty treatment and some DIY nail care supplies - scented oil, hot water, a basin, some orange sticks, cuticle trimmers if you're into that sort of thing, a nail buff and nail lacquer.  

Keep those little piggies fungus and TB free!

IgE-nough already!

Allergies suck.

NewFNP, while having perfect blood pressure and pure, blissful euglycemia, is plagued with allergies.  All manners of cats, grasses and trees lead to newFNP's desire to scratch her eyes out with pitchforks and occasion a series of sneezes so violent that a lesser woman might wet herself.  These unfortunate symptoms seem mild when compared with newFNP's food allergies.  

While newFNP's aforementioned environmental allergies began in childhood, her food allergies started as an adult.  Apples and tomatoes were the first to develop and were made worse by newFNP's daily consumption of both snacks prior to figuring out that they were the causes of her swollen, vesicled lips.  Nectarines are the most recent victim of newFNP's jacked up immune system.

Why is it that newFNP could not be allergic to a fruit that she is not so fond of, such as papaya or naval oranges?  Hell, newFNP would even trade in satsumas if she could have apples back.  The only thing that made her evolving food allergies tolerable was her super hot allergist at her grad school's health center.  

NewFNP, however, is lucky as far as food allergies go.  Not-a-once has she experienced that dreadful tingling in the throat, angioedema and pruritis - to say nothing of the hypotension and polyuria - that are hallmarks of an anaphylactoid reaction.

The crappy thing about a food allergy is that one can enjoy something, such as a Pink Lady apple, for her whole life and then all of the sudden become sensitized to it.  The next bite triggers the reaction and from then on such an unfortunate soul must find another healthful snack.

So goes her thirty-odd year old patient who has, until now, enjoyed a lifetime of grapes.  

Delicious, full of polyphenols, easily transportable and a major component of wine = newFNP's seal of approval.  That is, except for when they cause your eyes, lips, tongue, soft palate and throat to swell up like you just walked into a beehive and you come into newFNP's clinic with a touch of respiratory difficulty, not yet distress.

For the first time in over three years, newFNP opened the crash cart and delivered 50mg IM of Benadryl to this gentleman's gluteus maximus.  

Truth be told, newFNP wasn't really expecting that he would perk up so quickly.  Within minutes, his tongue and palate were back to normal size and his previously swollen shut right eye was open and clear.  Lungs were perfect and respirations were not strained. 

Benadryl, people, is a wonder drug.  NewFNP kept him in the clinic for a few hours and monitored him repeatedly.  She wrote him a prescription for an EpiPen, tested him for other food allergies, told him to stay the hell away from grapes, gave him some Benadryl and precautions/ instructions for the road, and told him to come back for his lab results, sooner prn.  

Grapes. 

What needs to develop is an allergy to McNuggets and Shamrock Shakes, to hot wings and chicharrones, but not to lovely fruit.  

Half full

NewFNP is either the luckiest or the unluckiest mamacita to ever roam the streets of her urban metropolis in a sweet Toyota Prius.

NewFNP would be hard-pressed, on any given day, to call herself an optimist.  This is especially so when she is frigging swamped with patients and when her MA is doing a dump of a job instead of her usual pretty awesome job.

But then newFNP has a night like tonight and she realizes that she is, in fact, a glass is half full kind of gal indeed.  But she isn't some fucking Pollyanna goody-two-shoes softie so put away your hankies.

NewFNP had finished a muy rico Cuban dinner with friends and left the festivities a little early to head home in order to be well-rested for her 8AM dental appointment.  In order to get from her friend's house to hers, newFNP has to drive through a not so savory area.  But seriously, who gives a fuck?!?  She wasn't planning on stopping and she works in a ghetto way crappier than this area.

Well, all of her plans of an uneventful drive home were shot to hell when some a-hole ran a red light, hit her sweet hybrid and sent newFNP literally spinning through the fucking intersection.  Although there were many, many other cars in the intersection, she was not hit by a single one during her tilt-a-whirl intersection adventure.  

She was hit on the driver's side, but is not at all hurt.  

The driver kept going.  Asshole.  Seriously.  100% certified asshole.

As this occurred in a super-crappy area, one of the witnesses waited with newFNP until the police arrived.  Really cool, right?  Big shout out to A.T. in the Google t-shirt for her total decentness and humanity.  

Well, what is not cool is when you're in a super big accident and you're in a shitty neighborhood waiting for the cops and some dickhead teenage gangsters start throwing fruit at you.

What.  The.  Fuck?  NewFNP kind of wanted to go vigilante on them, but what is she going to do?  Hit them over the head with her fancy university coffee mug?

NewFNP made it home safely after having filed a police report with some super cool lady officers.  They took the hit and run's bumper - sans license plate - and hubcap for evidence.   Does the manufacturer put a VIN on a hubcap?  No, right?  Oh, that would be some sweet justice.

This is the second time that newFNP has been involved in a major hit & run in a crappy area of town.  The first time, her car was in the shop for three months.  It was a $14,000 repair.  NewFNP was peppered with flying glass yet walked away unscathed, if not a little shaken.  

Today, she did a wide-arced 180 in a busy intersection and is not even sore.

NewFNP is lucky.  And it's nice to realize that she is, in fact, an optimist after all.

That tune might change, however, when she writes yet another $500 deductible check to the repair shop.  Crate and Barrel Petrie chair, you'll just have to wait.

Neti's Girl

It is not often that newFNP falls ill, but when she does, said illness tends to knock her on her ass.  The convalescence is short, but miserable - especially when it falls on a beautiful sunny Saturday.  

This period of debilitating lack of energy brought newFNP to a couple of realizations.

For one, newFNP is fucking over not having cable.  Who, in their darkest hours of viral illness, should be further traumatized by having to watch network Saturday TV?  Sure, newFNP could have read, but if she is too exhausted to order Thai delivery because it would require her walking downstairs to retrieve her Tom Yum Gai, she is too freaking tired to read.  Seriously, it's not like newFNP has People and Us Weekly lying around. 

It was somewhere during the 8-hour Lipstick Jungle internet streaming marathon that newFNP realized that cable and a DVR were in order.  November 22 cannot get here soon enough.  This is not to say that LJ is a bad show as far as S&TC rip-offs go.  NewFNP had never seen it before and thinks that Lindsay Price is as cute as the day is long.  She was thrilled to see her Crate & Barrel couch in Nico's office.  But don't let that clean white upholstery or the Crate & Barrel sales people fool you - the flawless white upholstery does not remain pristine, even in newFNP's childless, petless home.

For two, the excruciatingly embarrassing neti pot is a must have for any illness involving sinus fullness/mucus/overall disgusting head cold repulsiveness.  It is a shameful bathroom entity which, like moustache bleach/wax and corn removal tools, should be hidden whenever guests of the romantic nature are visiting.  But, man alive, does it ever work.

NewFNP is on the mend, so much so that, after finishing the Sunday NYT, she is planning on visiting the Nordstom half-yearly sale.  Clearly, the dawn of a new day.

Yes We Can

NewFNP expected that Obama would win as she stood in line at the polls early this chilly morning, but she must confess that the win feels so much better than she had imagined.  It is exceedingly rare that newFNP tears up when listening to a speech on TV, but tonight was an exception.  Two times she got a little misty - once for President-elect Obama's speech, and earlier during McCain's concession speech as well.  If the McCain who spoke tonight would have campaigned instead of the meanie who capitulated to his party's rightest wing time and time again, perhaps there would have been an actual Presidential race.  

Instead, a landslide.  For once, newFNP and Karl Rove's predictions were in accord.

NewFNP feels like it is truly the dawn of a new day.  She wants to bask in this good day sunshine feeling and ignore the fact that three states appear to be voting in bigotry in the form of gay marriage bans and a forth has embraced discrimination in banning unmarried "sexual partners" from adopting children.  Brad and Angelina - heads up.  Do not move to Arkansas.

But newFNP is off to bed, a smile on her face, dishes and wine glasses piled high in the sink - invigorated and hopeful for this new chapter in our history.

Yes.  We.  Can!!!

Election Eve

Oh.  My.  God.  

If newFNP never has to hear the word 'nucular' again, it will be too damned soon.  

NewFNP is so freakin excited for tomorrow and for a big Obama landslide (fingers crossed).  She will be at the polls bright and early and will be liberally abusing her clinic's personal internet use policy between every patient, monitoring the early returns.  

Oh, how newFNP loves election day.  She thinks that her friend's four-year old grandson expressed the feeling best while going through his swearing phase, declaring, "I am a fucking American!"  Watching the returns is so exciting!  It's like Oscar night for nerds.  

NewFNP had planned to cook turkey chili for the occasion, a newFNP specialty and an American favorite - pleasing in red and blue states alike.  However, she decided on seared sea scallops with herbed red potatoes (ironic, eh?) and garlic-infused baby broccoli - a more sophisticated meal perhaps better suited to the changing of the guard.  

Anyone want to come over?  

More Mirena

Again with the Mirena hatin'!  Different patient, of course.  NewFNP is trying not to take it personally.

Clearly newFNP needs to do a neurology CME to try to understand why the brain would cause a normally reasonable enough woman conclude that her headache of three days duration had its etiology in her IUD which newFNP placed a full five months ago.  

And then, what stops someone from just popping a Tylenol or two?  NewFNP finds this to be such an irony in her clinical population.  No one hesitates to borrow a penicillin or a couple of tetracycline when they have a cold or eczema or whatever.  But to take an over-the-counter analgesic - not gonna happen.  Better to just head on into the free clinic and get some Tylenol there.  

WTF?

Back that ass up

NewFNP got totally bitch-slapped by the universe.

Two months ago, she placed an IUD in a 38-year old G7P8.  This woman was certain that she was done with childbearing and that the IUD was preferable to a BTL.  NewFNP is privy to this woman's complicated social history and agreed that an IUD was a good choice.  We reviewed adverse effects and benefits, signed informed consent and went for the placement at the next visit.

The insertion went smoothly, as one might expect with a woman who has had 8 vaginal deliveries - even of her twins.   That was the last smooth experience newFNP has had with this client.

The next day, she returned to the clinic stating that she wanted newFNP to remove her IUD.  She had read the entire pamphlet and was disturbed to learn that women may have tubal pregnancies with the IUD.  Yes, newFNP explained, but women are at risk for ectopic pregnancies anyway and lowering your risk for pregnancy also lowers your risk for tubal pregnancy.  While her patient was surprised to learn that women could have pregnancies outside of the uterus, she was nonetheless unsatisfied with the IUD and wanted it out.  

NewFNP said no.  

She encouraged her patient to give the IUD some time, to think about the risks to her family and to her mental health, to say nothing of the AMA-related risks, if she were to have another pregnancy.  NewFNP told her to give it 3-6 months and if she was still unhappy, then we would again talk about removing the IUD.

She has been back three times since then.  Twice, Dr. Dual-Ivy-League-Degrees told her the same thing.  The third time, the new all-around-feather-ruffling doc told her to come back in a week and someone would take it out.  

She showed up the next day and waited for five hours for her three minute IUD removal.  NewFNP was all bunched up about taking it out and thought it would be a good learning experience for her PA student to take out the frigging thing.  

Before everyone gets all up in arms, 0f course this patient has the right to use or not use whatever family planning method she would like to use.  Of course she can have as many pregnancies as she wants to have.  But she doesn't want to be pregnant and she hasn't exactly excelled at contracepting in the past.  And now she wants to use "gel" to avoid pregnancy.  What?  Gel?  Like hair gel?  Gonna put some TRESemme up there?  Gel???  What about a fucking condom??  The pill?  The ring?  The patch?  The shot?  A diaphragm?  A tubal ligation?  There are many effective methods but gel, sister, is not one of them.

So newFNP did some alternative method counseling and got her student set up to remove the thing, fuming inside about this utterly failed attempt at decent, reliable contraception and feeling a little pissed that she was taking the IUD out.  As she maneuvered her student's instrument tray, newFNP backed up - ass-first and slightly bent over in order to visualize what her student was doing - and hit her butt on the corner of the counter in the exam room.  

Oh, the velocity of her movement.  NewFNP does not know her own strength, even when conducting a seemingly benign activity like backing up.

A shockwave ran down her leg and up her spine.  She wanted to cry out "Mother fuck!!!" but she didn't want to entirely destroy the already shaky encounter.  If this were a different kind of site, newFNP would post a picture of the impressive purple bruise that has caused her untold pain and has served to remind her about that shithole of an encounter and that her patient can do whatever she wants for birth control, that it's newFNP's job to educate, guide, encourage and prescribe, and that she should just keep her judgments to herself and take that fucking IUD out and move on.  

NewFNP knows all of this but she does want to point out that this IUD costs around $500 and that its cost-effectiveness is really not seen when someone has it for two freaking months.  

Got Gardasil?

NewFNP had two HPV-related teen pregnancy issues today.  Both were really sad and unsatisfying, both to her patients and to herself.

NewFNP's first HPV lady is a 16-year old 259-pound 35 weeker.  She has gained 47 pounds this pregnancy, far surpassing the 0-15 pounds newFNP recommended at the outset.  At pregnancy diagnosis, she had chlamydia and a low grade lesion on her pap.  NewFNP referred her for colposcopy - she didn't go.  She was scared, which is understandable, and her mom counseled her against going, which is less so.

After several visits of encouraging her to get the colposcopy to no avail, newFNP said fuck it and repeated her pap, hoping that her youth would wrestle that HPV into submission and normalize her pap.

Alas, it's now a high grade lesion.  

NewFNP resubmitted the colpo referral, acknowledged fears, stressed patients' rights and informed consent and strongly encouraged this young woman to not blow off this evaluation.  

The second 16-year old HPV lady also had chlamydia at pregnancy diagnosis and has recently been diagnosed with external condyloma acuminata, or genital warts.  You may recall newFNP noting how she had newFNP pulled out of the exam room to share this "emergency" with her.

She returned to clinic today, concerned that she had a yeast infection.  NewFNP placed her in the lithotomy position, noted the external warts - which now seem quite petite - and placed the speculum.

What greeted newFNP briefly forced her to consider that her knowledge of the female genital anatomy was really, really inadequate or like maybe she was in the wrong body cavity - a cavity she has never before seen.  The exam begged the question: what percentage of the surface area of the vaginal and cervix can be covered with condyloma before one considers c-section?  

Greater than fifty percent?  Seventy-five?  Fifty percent vag, fifty percent cervix?  This is something that is not in newFNP's textbooks.  It is likely something that one picks up from a wise mentor with years/decades of OB/GYN experience or years of your own OB/GYN clinical experience.  

NewFNP knows that there is a chance of extensive laceration and poor ability to suture the lesions during a vaginal delivery.  She assumes that this risk is increased when one's cervix is almost unrecognizable due the presence of extensive large verrucae.  And then, once the baby exits the cervix, it must make its way down the cobblestone canal-o- vaginal warts. 

Baby, keep that little toothless mouth closed!  Not that laryngeal papillomata are so common, but newFNP is just sayin'!  An ounce of prevention, ya know.  

As newFNP does not do deliveries, she arranged a consultation with the team that does.  

These young women just can't catch a break.  They have fucked up lives, fucked up parents, fucked up partners (neither of whom stuck around to support these girls during their pregnancies) and multiple STDs.  

And they're 16 and pregnant.  Mercy.

Dutch treat

NewFNP is in a bit of a pickle.  

You see, newFNP really values cute shoes.  But her plantar fasciitis is killing her.  And delicious though her sweet J. Crew Liv flats might be, they offer her no support at clinic.  And for the love of Pete, she can't wear her Cole Haan/Nike numbers each and every day!

So newFNP has been doing some thinking.  A long-articulated goal is a life of physical activity.  Sure, she tore her ACL and has a knee chock-a-block full of arthritis.  No worries - she'll just stay out of the snowboarding jump parks and enjoy the serenity of the smooth, long runs and maybe just take a little hop here and there.  And, yes, it's true that her mid-tibial tendinitis did get so severe that her physical therapist threatened to put her in the boot.  As if.  OK - so she has sacrificed her running and would now be hard pressed to run a mile although, truth be told, she hasn't recently tired.  But she wants to, goddammit, how she wants to!  And now with the fucking plantar fasciitis.

Well, she's thinking of returning to the supportive arches of the Dansko clog. Oh sweet Jesus, she feels a pang of sartorial resignation in even thinking it.  But BostonFNP wears them and looks so smart.  Dr. Dual-Ivy-League-Degrees looks cute as a button in hers.  

But newFNP will just feel like a big frump.  This is why newFNP is totally pathetic.  Who gives a fuck if she looks Dutch frumpy at work?  Only newFNP cares about that.  But she might just buy those fuckers anyway because she does not want bunions or plantar fasciitis or heel spurs or any of their associated surgical or aesthetic sequelae. 

If she goes with the patent leather option, that could be cute.  Right?  Maybe even with a new pair of AG jeans, right?  

Right?!?!!

Research + Clinic = Perfect Situation

NewFNP is going to let you in on a little secret: she likes clinical practice more than research.  That could be because newFNP has an inherent distaste for all things new or it may be because the research clinic is in a slow-as-molasses phase, but newFNP is - and boy does it ever pain her to say it - bored. 

That being said, newFNP was about to stroke out today when she had already seen 17 patients before high noon.  Or when her 16-year old pregnant math whiz had her pulled out of the exam room to talk to her about an emergency - genital warts.  

But she loved it when her absolute favorite patient, a 6-year old boy, ran down the hall to give her a big hug, show her his missing tooth and proceed to chat her up about Spongebob and Patrick and show her his perfect penmanship and numbers.  And it made her feel really useful when her 30-year old pregnant patient, who had been tearful in the exam room due to problems between her and her baby daddy, dropped newFNP an e-mail, letting her know that she was doing OK and would be in to see newFNP next week.  

NewFNP is making connections with her study patients as well, but there are three of them and newFNP works for eight hours.  Three patients, 8 hours.  Thirty-three patients, 8 hours.  For the love of sweet baby Jesus, can newFNP find a happy freaking medium?  

Anyway, making these new connections and valuing her continued connections with her clinical patients is really quite lovely.  It does bring newFNP a feeling of doing good for her community, for her individual patients and for herself.  NewFNP set out to be an NP because she wanted to have a meaningful career which brought her joy and promoted wellness in the lives of others.  Burnout sort of negated all those philosophical whimsies that newFNP had articulated for herself.

So, in sum, newFNP supposed that her current combination is working for her.  Bored or not, she does love going into work at noon three days per week.  This affords her the opportunity to go to Weezer concerts mid-week with her BFF and not be exhausted the next day.  It allows her to peruse chic glasses frames and ultimately decide on a sweet Kate Spade pair ("Elisabeth" in case anyone wants to be twinsies) with all the time in the world, nary a care in her mind except which glasses are going to make her look like a smart and sassy.  And thank goodness she has the time to exercise because her research job is largely sedentary and newFNP wishes to prevent work related ass spreading.  

And working part-time in clinic cures burnout.  It took a while for her pseudo-PTSD symptoms to subside but now they have.  

NewFNP just doesn't feel fried anymore.  

Mathematics

In newFNP's clinic, we are sticklers for identifying prenatal depression.  God help you if we diagnose it, but damn it all if we don't assess for it at bloody every visit!

The manner of assessment is a form called the PHQ9.  It is a series of nine questions developed to elicit depression via a Likert Scale of 0-3.  Generally, the patients fill it out as they wait behind closed doors for their provider.  Sometimes they tally the score; other times they leave that piece to newFNP.  NewFNP is cool with it either way as it takes her a nanosecond - plus or minus - to tally the thing.

This is sort of what the PHQ9 looks like:

I feel tired.   0      1      2      3

I have less energy than usual.            0      1      2      3

My appetite has changed.                   0      1      2      3

... and then six more questions.  Zero means not at all, three means quite a bit.  

Easy peasy right!?!

At the bottom of the page, there is a space to tally up one's result.  It looks like this:

______ + ______ + ______ = ______________

Makes sense, does it not?  Add the column directly above and write it down.  Then, add the three totals.  

So today newFNP looked at the PHQ9 of a 16-year old pregnant woman with a not altogether ideal social situation and saw 6 zeroes, 2 ones and 1 two.  Not too bad!  This young woman did the tallying herself and it went a little something like this:

___6___ + ___2___ + ___1___  = ______________

Is everyone with newFNP?  Six zeroes = 6, two ones = 2 (correct) and one two = 1.  Hmmmm.  Now, newFNP understands what she was doing, but what this young lady misunderstood is that we are looking for a cumulative score rather than for the frequency with which each answer appears.  

Then, rather than adding left to right, this lady did math the old fashioned way.  On the side of the paper, she had written:

62

+1

__

63

Not 6 + 2 + 1.  62 + 1.  And newFNP though that she had mathophobia!

Grand PHQ9 score: 63.  On a scale of 0-27.

In newFNP's institution of education, we spoke frequently of scaffolding our pediatric and adolescent patients who were experiencing stressful times, illnesses, etc.  NewFNP does a fair amount of scaffolding with this client - much more so than with her non-adolescent prenatals.  But she is not sure that there is enough scaffolding in the world to counteract the effects of limited IQ and a fucked up social situation coupled with the impending birth of a child.  

Schadenfreude

NewFNP wants to say right off the bat - take that O.J., you murdering, armed robbering, kidnapping motherfucker!  Sure, you got away with murder, you SOB, but you couldn't just walk the straight and narrow and the good people of Las Vegas were wise enough to do what the people of Los Angeles could not thirteen years ago.  NewFNP supposes that murdering two people loads you up with bad karma.  Further felonies do not help.

OK, back to newFNP.  In her new job, newFNP is surrounded by overachieving braniacs.  Hell, in her clinical job as well, but in her clinic most people are content with providing clinical care.  In her new job, clinical care is part of what you do when you aren't taking an 8AM course in genetics as a fun refresher or being a RWJ Clinical Scholar or writing new research proposals.  NewFNP is in the fucking thick of academia in her new gig.

To newFNP, academia is like her fantasy world of smart people just getting to be smart and do smart things and make smart geeky jokes about acetylcholine and dopamine.  It's where miracles happen - where genomes are sequenced and viruses are isolated and treatments are cutting edge.

So newFNP really has a lot of opportunity to grow in her career.

The thing is, newFNP isn't sure how much she wants that anymore.  Sometimes newFNP just wants to read Go Fug Yourself or For Whom the Bell Tolls or the New Yorker.  Sometimes she just wants to get her teeth whitened or her face facialed.  She wants to go to a movie or a Weezer concert or the opera.  Or she wants to write here on her blog, which she fully acknowledges is not advancing the science in any way but brings her a lot of joy.  And what if she wants to have a baby one day?

Recently, newFNP's new supervisor mentioned that he hasn't been to a movie in years.  Incredulous, newFNP asked why.  He stated that he doesn't have time.  No time?  For a movie?  Not even for a George Clooney movie?  That is not the life for newFNP.

And newFNP feels a little guilty about this.  Like she is letting her new boss - of three weeks - down.  Like she isn't living up to her potential.  Like she is a big flake for not taking on more and more responsibilities.  

But, for now, she'll just go read some Hemingway and put her professional neuroses to bed for one more night.