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.

Lolly Lolly Lolly Get Your Mirena Here!

A while back, newFNP noted that she was caring for a pregnant seventh grader who was not on track to win any genius awards.  This young woman continued to astound all who came in contact with her throughout her pregnancy, which ended happily - though not without adolescent high jinx - on Saturday.

NewFNP's clinic contracts with one hospital.  This hospital is where each and every one of newFNP's prenatal patients are expected to deliver.  It is where they go on hospital tours.  It is where they pre-register for their intrapartum care.  

There is no equivocation in this expectation.  There is no gray area.  One.  Hospital.

So, when the anti-MacArthur Fellow went into labor, newFNP would have expected that she would grab her bag and her copied ACOG form, and would have said to her boyfriend (who, thankfully, was sprung from juvenile detention prior to the big event - WHEW!), "Hey stud, take me to General Hospital."  General Hospital, of course, meaning the one specific hospital where she was repeatedly told to present when the time came.

That is, in fact, not what she did.  Apparently, impending childbirth was not enough of an adventure.  These youthful imps decided to try a different hospital.

A convalescent hospital.  

Seriously?  Even if their combined IQ is still less than the price of a loaf of bread, one would think that they could appreciate the difference between a convalescent hospital (single story, wheelchairs and walkers strewn about, aroma of BenGay) and a regular hospital (multi-story, bright red 'emergency' sign, ambulances).

After a quick transfer via paramedics to a regular hospital, these Mensa members became parents.  

There are not enough hours in the day for newFNP to explain the many and multi-faceted reasons why this terrifies and concerns her.   

Are we still wanting abstinence only education?  NewFNP votes no.  In fact, she is thinking of running for mayor, congress, queen, master of the universe - whatever - on her free Mirena platform.  She'd run for president, but she's not old enough yet.  But son of a bitch if that isn't right around the frigging corner.  

Crud.

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

Shana Tova!

Oh baby!

People, it is no great secret that people have complicated lives.  NewFNP has seen a shitload of this in her expanded role as prenatal care provider.  

Take for instance the 20-weeker who complained of daily anxiety and thoughts of fleeing.  NewFNP screened for abuse.  Denied.  Depression?  Denied.  Pre-existing stressor?  Affirmed.  What stress might that be?  Her on-going affair resulting in her unintended pregnancy resulting in her uncertainty as to half of her fetus's DNA.  NewFNP offered support and referral to counseling but felt a little relief when her patient flat out acknowledged that she had made her bed - no pun intended - and that she would have to find a solution.  True.  But take the referrals, hon.  Clearly there are some issues to be worked through chez toi.

Or the 17-year old pregnant woman who tested positive for HCV.  This 17-year old now has to worry about vertical transmission (0-8% risk), about breast-feeding (CDC and AAP say it's OK), about hepatocarcinoma (referral, viral load, genotype pending).  

Or the 30-year old G6P3 who recently separated from her partner, had an unintended pregnancy and - surprise!!  Triplets!

Now, newFNP has generally refrained from turning her blog into a platform for political musings, but here we are in an election where one ticket is opposed to abortion rights no matter what and supports the limited to access to birth control, where the VP candidate wants women to pay for their own rape kits and ban Are You There God, It's Me Margaret, and where the presidential candidate is a huge dick during the debate he tried to bail on.  OK, that last one isn't related to health care, but he was a dick, right?  Geez!  

Do they want more 14-year old parents with limited IQ and limited future prospects?  If newFNP were running for president, she would support free Mirena insertion at age 14 for all females.  Isn't it reasonable for the whole country to delay childbearing to age 19?  Just get through high school?  Fuck, get through middle school without getting knocked up.  

NewFNP was a die-hard Hillary supporter, but she does not at all understand these people who have jumped from Hillary to McCain/Palin.  What the fuck?  Women's rights people!  Remember 'women's rights are human rights'?  Taking care of the poor?  Gay rights?  Not screwing the middle and lower classes?  Valuing education?  Valuing science?  Promoting environmental awareness?  The economy?  Not having nuclear war with Iran?

Oh man, newFNP cannot imagine the consequences of a McCain/Palin White House.  The only good thing that could come of it is more Tina Fey impersonations and, as ridiculously great as that was, it's not enough.

Win-win situation

As many of you know, newFNP was in the midst of a crisis when she made the decision to make a change of venue.  She was really concerned that she had made a huge mistake in becoming an NP.  It was altogether quite unpleasant.

Well, that has all changed.  NewFNP cannot believe her new job. She cannot believe her new attitude.  And she cannot believe her new schedule.

 The downside of the new position is that is holds less responsibility than her clinical role. This will change when newFNP is not so new there, but for now newFNP is feeling a little underutilized.   The upside is every-frigging-thing else.  NewFNP went to lunch today with her colleagues.  Lunch.  Away from the clinical site.  With her colleagues.  The support staff are entirely competent and responsible in their roles.  NewFNP has been told by her supervisor to 'relax' and 'take it easy' - not just once.  Multiple times.  The job is all about attention to detail, about taking your time and doing it right.  It has EMR.  It's 2.5 miles from her apartment.  What's not to love?

And, sweet Jesus, the hours are 12-8PM.  To newFNP, this is a dream come true.  No more fighting in lines at the gym to get the good elliptical machines at 5:30PM, no more blowing off the gym to cry about one's shitty day.  Now the gym is a pre-work activity and not at 5:30AM and not when there are a million other people looking at newFNP is she tries to sneak in a 40 minute workout instead of a 30 minutes one.  Now she can guiltlessly enjoy her full 60 minutes of cardio.  She went to the grocery store - a perpetually crowded grocery store - and it wasn't crowded.  It's a whole new world!  

This must be what it feels like to find religion.

But maybe the best part about being at the new job is that newFNP enjoys the old job a million times more.  This is not to say that she does not experience frustration when she has three 1:30 appointments, but she has adopted a much more zen-like attitude about it.  Saying well, fuck it, I'm not here tomorrow qualifies as zen, right?  In the face of new responsibilities at the new job, newFNP is thankful to feel mastery, or at least competency, in her clinical role.  

Hello awesome!

Oh my god, newFNP never knew that work could be so good.  So fucking good.  So.  Fucking.  Good.

New Job's Eve

NewFNP is nervous.

Sure, change is good, it helps/forces you to grow and learn, it broadens your horizons, it affords you a bigger paycheck and a shorter commute - at least in this instance.  But, fuck, change can suck.  Role transitions are challenges, even when we are prepared for them, even when we have been longing for them.  Being new anew.  Learning each and every aspect of one's position again. 

All of newFNP's friends and family are telling her that the new job is perfect for her - it's organized, protocol-driven and academic in focus.  Hell, that's a fairly decent description of newFNP herself!  

But, ugh, change.  Even though her new supervisor is all about easing newFNP into the job, there lurks that part of newFNP that is worried that she will fail.  Why would she fail?  Who the hell knows, but she's still scared of it.  

NewFNP saw some movies this weekend, bought some flattering black trousers and designer jeans and is enjoying her last night of vacation with a glass of wine and some EKG review.  

Shopping, wine, George Clooney and studying: something(s) old for tonight, something new for tomorrow.

NewFNP: vacation lady

Quite a difference from an urban health clinic!

NewFNP loves vacation so much that she wishes she could turn it into a profession.  Alas, as newFNP's mom used to say, it's too bad that we weren't born rich instead of so good looking!

NewFNP has had a lovely time off and actually feels rested enough to start her new job as well as returning to her old clinic.  This fresh glow will fade rapidly, to be sure, once the pulls of clinical life begin anew, but that is in another five days, so in the interest of continued mental wellness, newFNP shan't focus on that.

In addition to spending a few lovely yet bearish and sometimes physically grueling days in a national park, newFNP had the pleasure of meeting a fellow alum of her nursing school - a woman, MLG, in her 90's who graduated in the 40's.  She currently lives in the same senior's community as newFNP's grandparents. When newFNP met her in the elevator, her enthusiasm was intoxicating.  NewFNP returned the next day to talk to her more.

MLG, after completing her bachelor's in English literature, headed to nursing school "to get away" from her family's expectations and to see the world.  She earned her first master's degree, then left the US to work as a war nurse in London.  She returned and worked as a visiting nurse for some years before heading across country to work at a very prestigious hospital as a pediatric nurse.  She left this position, however, when she disagreed with the policies of the ward - noting that they would give the active children phenobarbital in order to calm them down.  She moved to another hospital, where yet another alum was the head administrative nurse, and worked as the chief of pediatric surgical nursing.  It was here that she realized her passion - "the emotional life of children" - and used her GI Bill benefits to earn her MSW.  She spent the rest of her life as a social worker.  When newFNP explained to her that the school now has a child psych NP specialty, her eyes lit up.  She noted how many more options students have now.  

NewFNP noted the different paths that she and MLG took to the doors of the same institution.  MLG chose her path to leave behind and explore, whereas newFNP actively chose, sought out, was wait-listed and then finally admitted to the school.  It speaks to the growth of nursing as a profession, does it not?  Perhaps this only applies to academic nursing programs?

Unlike newFNP, this woman lived in the nursing dorm and had little contact with students from other academic foci.  The nursing and medical schools were separated from the main campus, as they are today, in a then-and-now seedy area.  NewFNP explained that, while there were still dorms for the health-professions students, she lived several miles from the school, in an apartment by herself.  MLG told newFNP that it sounded like newFNP had a lot more fun than she did during nursing school.  Probably very true; newFNP had more than her fair share of fun in school!

Like newFNP, MLG was a part of a group of six friends who have continued to meet regularly for retreats.  Like newFNP, she considers this group of women to have been one of the most valuable aspects of her time spent at this very prestigious and academically rigorous institution.  It's funny - newFNP considers her education to be vitally important, but she could have learned nursing at many institutions.  Her friends, however, are irreplaceable.  MLG's group now numbers only three.   

Meeting this woman was a gift for newFNP.  What a lovely experience to share.

Gimme some sugar

NewFNP sees diabetes each and every day. Double digit A1Cs are, sadly, all too common. But she has very few patients who are as bad off as her 23-year old diabetic with an A1C of 15.7. The lowest A1C she has ever had since her diagnosis in 2006 was in the 13's.


Generally, during her all too infrequent clinic visits, this young woman presents with sugars above the limits of detection on the clinic's glucometer. Once, she came to clinic almost unresponsive in a hyperosmotic - hyperglycemic state (HHS) - mouth dry as a bone and in and out of consciousness. NewFNP sent her promptly to the ER. She passed out another time in the supermarket and again, was sent to the ER in HHS. This last time, she felt herself reaching that HHS point and called the paramedics herself. That's good, right? Understanding one's symptoms and acting accordingly. Sure, a little prompter intervention would have been prudent, but newFNP is feeling generous tonight.


She spent a week in the hospital and left with a glucose of 130, according to her discharge summary. She had prescriptions for insulin, but had not been able to afford the medication when she presented to newFNP's clinic the morning after her discharge.


Her glucose less than 24 hours after hospital discharge? HHH.


NewFNP got her to a detectable level after 30-something units of insulin in clinic, did insulin instruction, diet education and sent her to the nutritionist. This was not the first time in three years that newFNP did diet education, but it is the first time that, when her patient told her that she had eaten two tamales and some pancakes for breakfast, newFNP stated, "That is just like putting a gun in your mouth and pulling the trigger."


Ouch.

NewFNP has never been one to respond to or to employ scare tactics, but she cannot tell you how many people have told her that they changed a behavior because someone showed them a picture of a foot with an amputated toe or because they saw their friend suffer from and STD, etc. Others providers have told newFNP that they use the patient's fear of adverse outcomes regularly in their counsling. NewFNP has just always felt that that is an ugly tool. If newFNP's provider would have said something like that to her, she would have thought, "Whatever- screw you." But newFNP said it and saw that her patient heard it - for better or for worse.


OK, so pretty harsh. NewFNP is certain that the nutritionist delivered the message in a more nurturing fashion.


Whatever message stuck for this patient, it really frigging stuck because when she can into the clinic yesterday, her glucose was fifty-frigging-one. In the course of the six hours newFNP kept her in clinic, this young woman consumed a 75g glucola, a 4g glucose tablet, a turkey sandwich, salad, fruit, a second helping of glucola - this time only 25g - and, thanks to newFNP's awesome student, a chicken breast from El Pollo Loco (thanks BC!). During the course of the six hours, her glucose measured between 45 and 215.


What the hell?


NewFNP reviewed how much insulin she was using and if she was using it correctly. She was. NewFNP therefore lowered her insulin doses and have her strict instructions regarding glucose monitoring, ER indications and follow up.


NewFNP likes to be an outlier if it is something like 2 standard deviations above the mean in fashion sense or test scores, but she does not like glucose outliers on either end of the spectrum. And she isn't sure why this young woman is all over the glucose map.


And now she'll wonder about this patient as she spends two luxurious weeks on vacation after only one more eight-hour shift this Saturday. She'll have to hit up Dr. Dual-Ivy-League-Degrees for an update.


NewFNP's service commitment ended today. Her six-figure nursing school loans are forgiven. Now she only has five-figure pubic health school loans with which to contend. Aaaahhhhhh! What a relief.

The final countdown

NewFNP's CEO signed her final loan repayment form yesterday.  Her last full-time day is one week from today.

There is not one part of newFNP that is sad to be leaving full time practice at her clinic.  And that makes her very fucking sad.

Provider burnout is not new.  Articles have been written, schools talk about it, practitioners live it.  And for what?  There is a lot of talk about a broken health care system in every media outlet to which one chooses to listen.  But it's not just the Medicare reimbursement or the HMOs and PPOs that are broken.  

It's organizations like newFNP's clinic - where the average shelf-life of a provider is less than three years; where there is not one hour - hell, there's not one minute - of administrative time scheduled for providers; where there is no one to follow up on referrals to specialists; where there is not one registered nurse, not one LVN, not one CNA; where providers work through lunch every day; where lab results, correct phone numbers and vital signs aren't in charts; and where patients are double and triple booked.

NewFNP is partially to blame for her own burnout.   But, you know what, her clinic is responsible as well.  It doesn't seem too far fetched to make efforts to take care of one's employees.  NewFNP's senior management believes that providers are just there to see patients, and as many as possible each and every day, all the while fixing the errors of other staff members, filling out endless forms and attempting to care for the physical and, often times, emotional well-being of the patients.

It's too much.  NewFNP isn't sure if it's her - if her lack of personal fortitude is the problem, or if it's the dysfunctional environment in which she works.  She thinks that, given her degrees from top schools, it's the latter, but it's not in newFNP's nature to let herself off the hook that easily.  Perhaps it just means that she needs to choose her next practice site more wisely, if she ever goes back to full time practice.  Perhaps she needs to impact health outcomes from a more hands off venue.  

NewFNP thought that she would be working with the urban poor forever.  She sought out a free health clinic in the frigging ghetto.  And now she wants to get the hell away from it.  That is sad. 

One thing newFNP can say is that she learned a lot these past three years.  And she continues to learn every day.  And that is a really lovely thing about nursing and medicine.  But when it's time to go, it's time to go.

And it's time.

Hemoglobin of 6

For those not in The Biz, a normal hemoglobin in roughly in the neighborhood of 12-16 g/dL.  NewFNP is not going to lose any sleep over an 11 or even a 10, but she will assess your gender and diet and overall health and pregnancy status and miserable menstrual periods and history of hemoglobopathies, yada yada yada.  

No, newFNP doesn't go into real worry mode until she sees hemoglobins in the single digits and, really really not until it's below 9.  

But what will get newFNP's attention faster than a J. Crew shoe sale is a hemoglobin of 6.  And that is exactly what newFNP has seen this week.  

Twice.

NewFNP's first crazy anemic patient is the 30-year old with AIDS.  He came in noting copious frank rectal bleeding times four days.  NewFNP saw him two weeks earlier and his hemoglobin was 10.  NewFNP placed him back on iron and instructed him to return to his HIV doctor.  He is taking the iron but is less adherent with his HIV care.  Some might say that his priorities are askew, but when your hemoglobin is 6 and you are bleeding from your rectum, newFNP doesn't have that chat with you.  She examines your bleeding after 5 minutes of hemming and hawing over the embarrassment about showing newFNP your b-hole, notes frank bleeding and transfers you to the hospital for transfusion and diagnosis of etiology.  

NewFNP spoke with his nurse at the HIV clinic a couple of days after his admission- he's hospitalized, transfused and recovering.  But, in reality, he is circling the drain.  He's failing his HIV appointments and taking his medications incorrectly and not taking all his prophylaxis meds.  It breaks newFNP's heart to see him suffering so much and to see him not adhering to his care.  Thirty years old.

The second anemic patient this week presented to clinic with vaginal itching.  She is 14 years old.  She wasn't with her parents because she's sexually active and doesn't want them to know.  NewFNP got her history and was about to begin her exam when she realized that she had forgotten to look at the lab section of the chart.  She flipped back and saw that the patient's hemoglobin was 6.1.  She asked the patient about heavy periods or dark stool or nosebleeds - nothing.  She thought that the MA must have made an error and asked her to repeat the test.  It was 6.3.

This brings newFNP to another point.  Both times, newFNP's MAs had no idea of the significance the very abnormal result held.  One MA is known to newFNP and she's not entirely surprised, but when newFNP expressed shock at the result and instructed him to repeat the test, he was in the patient's exam room, repeating the test in a fricking flash.  NewFNP saw the second patient in a clinic that is not her regular site as she was filling in for a provider who is on vacation.  Unlike the MA at newFNP's regular site, this MA did not seem very impressed with newFNP's instruction to quickly repeat the test.  Frustrating.  But it does bring to mind a few lessons:

1. Repeat abnormal values.
2. Work with the same MA so that you can teach him/her abnormal values that necessitate your attention.  The same MA who blew newFNP off when she asked her to repeat the hemoglobin also let a post-CVA hypertensive woman sit in the lobby for two hours after having recorded a blood pressure of 198/110.  NewFNP was displeased.

NewFNP called the fourteen-year old's mother, told her that her daughter wasn't feeling well and had come to our clinic where we detected this anemia.  Her mother told newFNP that she was anemic because she didn't take vitamins or eat well.  Hmm, not the most common reason for a hemoglobin of six, but very motherly, no?  NewFNP told her that her daughter might need a transfusion and could she please come to the clinic.  

NewFNP's big worry is cancer.  She's not sure if she'll ever know what happened with this young woman but she doesn't have a good feeling about this one.  

La cucaracha! La cucaracha!

There are a great many things that newFNP does not want in her ears.  Wall-o-wax and slurpy tongues come to mind, but much, much higher atop that list is anything on God's green earth that has an exoskeleton.

NewFNP had almost made it to three years of practice without having had to retrieve the dreaded cockroach from a child's ear.  Her perfect record was spoiled yesterday.

NewFNP's 14-year old patient came in with the complaint of three days of ear pain.  Generally, when a teenager has an OM, newFNP sees some distress, some fever and some lymph nodes.  This young lady had nothing but distress.  As newFNP manipulated her pinna to get a good look inside, she felt a good deal of distress as well.

At initial glance, newFNP just knew that something was rotten in Denmark.  She had never seen wax look so symmetrical.  "No," she thought to herself.  "Please, no."  She looked around a bit more and saw an unmistakably roachy leg -- a little spindly tibia with its little roachy projections just sitting there, taunting newFNP and begging for removal.

After years and years of evolution, why is it that these most dreaded of pests have not developed the ability to move in reverse?  And, when entering an ear canal, why do they not sense danger and just stop?  And, once in, why do they keep going?  They have both eyes and antennal flagellae!  What the fuck?

At any rate, newFNP was faced with a dastardly combination: traumatized, crying fourteen year old who was in physical pain (to say nothing of the emotional torment one must feel upon learning that your ear is a cockroach garage cum coffin); big roach parked deeply in the ear canal; and tiny freaking ear canal.

NewFNP attempted mechanical extraction but was categorically denied.  She then moved on to irrigation in an attempt to move that M.F.-er to a more reachable place.  At this point, her patient was close to losing it.  

NewFNP made a reach and removed... a thorax.  She looked inside her ear and could easily see tissue-paper thin wings wallpapering her patient's TM.  

OK, cockroach!  You win, you fucker!  You bested newFNP.  NewFNP set up an ENT visit for the afternoon and sent the poor girl on her way, half a cockroach nestled in her tiny ear.  

Bummer.

NewFNP is a jerk

NewFNP is reading an article about burnout and she sees herself in it far too frequently. 

She feels like an utter failure.  NewFNP hasn't really ever given up on something, but she is so relieved that she is giving up on her community health practice.  And she is so ashamed to feel such relief.  

But she is snapping at staff members (irritability) , she feels burdened by patients (frustration) and notices that she feels less compassion in the exam room at times (apathy), she dreads going to work (despair).  

In retrospect, she should have taken more vacation.  But she has coping mechanisms and she uses them.  They just don't work anymore (emotional exhaustion).   

To newFNP, that all screams failure and the cumulative effect is breaking newFNP's heart.  This is not how she wants to behave and feel.

Two more weeks.  Hope springs eternal for newFNP -- she hopes that when she is working part-time, she won't be such a huge asshole.  Can she just stay in bed for the first two days of her two-week vacation?  Can her friends and family gather at her bedside and bring her Lucky Charms?  Will a facial and a peel brighten her outlook?

NewFNP hopes so, because she wants the old newFNP back.

Phone-y baloney

There are maybe two cell-phone conversations which newFNP would like to overhear.  

One goes like this, "Hey Brad Pitt, this is George Clooney calling.  I am absolutely awestruck by the beauty and witty repartee that I have been enjoying with this lovely NP sitting in front of me.  I do believe that I shall fly her to Lake Como on my private jet and bed her."

The other may be something along the lines of, "What - they are giving away free flattering Theory trousers and cashmere sweaters at Bloomingdales at exactly 5:00 today?!?!"

What newFNP does not want to hear is your bullshit whatever conversation while she is attempting to get a health history on your two-year old kid during his physical exam appointment.

Can you hear newFNP now?  Hang up your goddamn phone!!!

For a solitary in-exam-room-phone-pick-up that is quickly ended with the words, "I can't talk now -- the newFNP is in the room," newFNP grants you a pass, but is nonetheless displeased.

After the second, third and fourth times, newFNP believes you to be unacceptably disrespectful.  During the fourth call, as the patient's mother was repeating an 800-number and credit-card number to the woman on the other end of her phone, newFNP exited the room, stating that she would return when the mother was more ready for the exam.  As she opened the door to leave, she overheard the mother stating, "Look - you made the newFNP leave" to the person on the other end.

Come again?  The woman who called - not knowing that the mother of the patient was in the exam room - bears responsibility?  No, ma'am.  

Sorry, sister, but one is not obligated to pick up the stupid phone while the provider is in the exam room.  In fact, one should be obligated to put the damn thing on vibrate or turn the fucking thing off after the first time it disrupts the clinic visit.

For the love of all that is holy, how do people not know this?  

911 on speed dial

EMS presence has been a regular feature are newFNP's clinic recently.  The trend started last week when newFNP had two ambulances at the clinic at the same time - a first for newFNP.

NewFNP's first ambulance-requiring patient was a depressed woman.  She came in complaining of headache, but her affect screamed depression.  As it turned out, she had two suicide attempts requiring hospitalization last year and was suicidal again.  She had a plan (run out into traffic) and means (busy urban area with lots of traffic).  She didn't trust herself to leave clinic and go to a psych appointment the next day.  She wanted inpatient admission.  

She got it.  

NewFNP called her local psych response team at 1:30.  She kept her patient in the room, supervised at all times.  The 'team', which was comprised entirely of one gentleman, arrived at 5:15 PM.  That is when he began his assessment.

NewFNP is a strict believer in not having anyone be alone in the clinic after closing, given that when the lights go down, the sex workers and drug dealers and rival gang member come out.  Adopting a team player attitude, and possibly to get out of his sister-in-law's wedding planning activities, newFNP's clinic manager agreed to stay with her until the psych patient was safely escorted out.  NewFNP and this 24-year old guy were just sitting around when he decided to take a peek outside and find out just where in the hell this ambulance was.  

He returned, clutching his head and telling newFNP that he needed the O2 mask.  Having had a mock code the day before, newFNP briefly thought that he was kidding.  

He was not.  He told newFNP that he had 'blacked out' and couldn't feel his left hand.  He was clutching his left parietal area and complaining of intense pain.  

At this point, newFNP had the suicidal lady and her mental health assessor behind closed doors in room 3, the clinical manager in the lobby and the custodian somewhere in the clinic.  NewFNP quickly assessed the manager, yelled for the custodian and ran to get the emergency equipment and called 911.  

The fire department arrived for the clinic manager at the same time that the first ambulance arrived for the suicidal lady.  It was 6:15.  The second ambulance, expecting to transport the clinic manager to the ED, arrived at 6:25.  NewFNP's clinic manager was hooked up to a portable EKG, normoglycemia confirmed, Romberg negative.  The suicidal lady, much more relaxed, was strapped into her ambulance gurney and departed for her psych evaluation.  

At 6:45, a handsome paramedic asked newFNP, "What time does your clinic close?"  "Five," newFNP replied.

At 6:50, newFNP's clinic manager decided, to newFNP and the paramedics' protests, that he'd prefer not to go to the emergency department after all.  

NewFNP and six firemen/paramedics can lead a horse to water...

Psyched!

NewFNP is no expert in mental illness, but she does know the difference between normal behavior and off-one's-rocker. 

Here are behaviors which newFNP appreciates as falling squarely outside normal.  Capturing pictures of the following subjects on one's cell phone camera: angels, fairies and elves who just hang out in one's bathroom mirror; heaven and hell (same picture); and men walking through clouds of fog on an urban city street.  Also included in this list are movements so exaggerated that newFNP was genuinely concerned about a major musculoskeletal injury requiring a neck brace.  And finally, a crescendo pattern to her speech on each and every subject addressed during the clinic visit - diabetes, soda, moms, returning to clinic the next day, etc.  

This is a patient for whom her support staff tried to room without a chart - a diabetic patient whose sugar was 'HHH' and, according to newFNP's diagnostic skills, is schizophrenic.   When newFNP finally got the chart, she reviewed the previous clinician's note, which noted in her general evaluation that she had an expressive personality.  Expressive?!?  Salvador Dali is expressive, this lady has severe mental illness.

A question which newFNP employs with some frequency is "Have you ever been under the care of a psychiatrist?"  Readers will not be surprised to learn that this woman's answer was 'yes.'  She told newFNP that she took Seroquel for two years after her mom died.    In newFNP's relative inexperience, atypical anti-psychotics are not first-line for prolonged grief.  NewFNP asked this woman if she thought she might need to resume her Seroquel treatment .  Much to her relief, her patient replied that she thought this might be beneficial.  

Psych referral completed!  Now if newFNP could only get her diabetes under control. 

Start spreading the news...

NewFNP felt the magnitude of her decision to leave her clinic as she saw the crestfallen look on her clinic manager's face when she told him that her last full-time day is fast approaching.  It's not that she didn't imagine that the transition from community health to academic medicine would be insignificant; it's just that she is ready to leave and has only been focusing on that.  But to see this young man's shock and disappointment, to hear him say, the patients are really going to miss you to have him say that he is sad - ouch.  

He also told newFNP, "But you are Franklin," the (fake) name of our clinic site.  Maybe yes, but that's part of the problem.  NewFNP just can't put her heart and soul into it any longer.  It's too hard and the forces against change are too great.  

"Two days?" he asked when newFNP told him that she would still be working part-time.  "Can't it be three?"

It absolutely cannot.  Somewhat sad though newFNP may be, she needs only to read her own blog to be reminded of what drove her decision.

NewFNP, apparently more of a pessimist than she had imagined, had feared that her medical director would be upset or feel betrayed or tell newFNP that it was all or nothing as she sat down with her today to tell her that she was hoping to stay part-time.  Instead, she was the perfect mix of happy and sad - happy for newFNP that she has this new, exciting opportunity in academic medicine at a top ten university and sad to see newFNP go.  She was absolutely supportive of newFNP staying two days per week and on newFNP's terms.  She even hugged newFNP.

Did newFNP dream this?  She hopes that the rest of the management team will be as supportive. 

As newFNP goes through her days, seeing her patients and thinking about the patients for whom she has cared over the past three years, she feels a heaviness in her heart.  She is choosing to give up being a primary primary care provider.  She is making herself unavailable.  She is choosing an amazing opportunity for career advancement, professional growth and day to day organization... all with meth addicts!  But meth addicts who want to quit and who are enrolled in a Phase 2 clinical trial - a controlled environment indeed.  She can walk or ride her bike to the clinic site.  She doesn't have to be to work until noon, allowing plenty of time for hiking and gym and yoga and grocery shopping.  Hell, she might even shave her legs more than once a week!

Although newFNP has been near tears thinking about making this change, it's the right decision.  

And please, newFNP knows that this is off topic and that she has made this plea before, but can she please go on What Not To Wear?!?!  Will someone please nominate her? She is starting a new job after all.  And even though dressing well is religion to newFNP, even she has fashion ruts - hell, she has three white v-neck tees and lives in her Juicy sweats every weekend!  Clinton and Stacy can tell her that she can still wear a pencil skirt even though her calves are thick and tattooed, they can tell her that she needs a new bra and they can drop her off in front of Theory with a $5000 visa card.  Carmindy can teach her how to do the smoky eyes and Nick can teach her to coax her curls into ringlets.  Please!!  For the love of flattering trousers!!  

Derm-mania

When newFNP started this little blog, she had fully intended for it to provide some helpful hints to new NPs and NP students, rather than solely using it as a sounding board for complaints and to vent her own personal frustrations.  To that end, newFNP would like to share a case with her readers.

As newFNP has previously noted, she really enjoys derm.  It is something that other providers, however, fear and dislike.  And newFNP understands - derm can be tricky and disgusting.  When the skin goes south on you, it can really go south!!  NewFNP works with one provider in particular who really dislikes derm and knows that newFNP really likes it.  She consults newFNP routinely on her derm cases and newFNP happily examines and provides sage (she hopes) counsel.

This provider pulled newFNP into the room today to show her an extraordinary lesion.  It was more than a lesion, really.  It was a breast plate of erythematous papules and pustules on an otherwise healthy mid-twenties man.  It was acneiform but newFNP immediately recognized that it was not acne.  His face and the majority of his back were spared.  There were no open comedones, nor were there nodules.  It evolved rapidly over the course of two weeks.  It was pruritic.  His alcohol-based Mexican topical medicine was drying his skin, but not his pustules.

As newFNP's patients love to ask her, mostly when questioning newFNP about the mysterious etiology of a long-gone headache or tingly fingers or gas, "Porque sera?"  Loosely translated, this means "Why could this be happening to me?"  Often times, newFNP doesn't have an answer.

This time, she does.

NewFNP has her money on pityrosporum folliculitis, a condition caused by yeast and frequently misdiagnosed as acne.  She'll let you know what the final outcome is, but she advised her colleague to check the patient's sugar and HIV status and to start him on a combination of topical (BID) and oral (200mg QD x 30 days) ketoconazole.  Clinical improvement with the anti-fungals supports the diagnosis.

This is so one of those cases in which newFNP should have snapped a picture with her camera phone and sent in the case to a journal.  But newFNP didn't think of that at the time.  Son of a bitch!  

Alas, fame will elude newFNP once again.

Not even on the list of differentials

A while back, newFNP saw a guy who came into the clinic and was quite distressed about the painful ulcer he had on his penis.  He somewhat bashfully showed newFNP the lesion which required him to retract his foreskin.  What was revealed was a bright purple glans with a single ulceration.  

The first time newFNP saw the purple liquid covering something or other, she was quite surprised.  Tincture of violet, or violeta, is a much loved antiseptic in the Latino community.  NewFNP's patients don't seem to use it as advertised in the natural stores - as a tincture of be consumed - but rather paint it on any manner of superficial injuries including, it seems, the ones that show up on the penis.

Despite the violeta, newFNP did a herpes culture - negative -  as well as a syphilis test - also negative.  Her patient wasn't giving up any clues as to what may have caused this ulceration.  No zipper misjudgment, no history giving newFNP a single damned clue about why his penis had a big fat ulcer.

Well, newFNP's colleague elicited a story that is incredible.  She saw this gent for follow-up, penis still purple and ulcerated.  According to her, he must have felt like confessing because he told her how he got the ulcer. 

NewFNP knows this man to have been a former crack user.  Apparently, he had been a crack dealer as well.  His storage space: the cozy area between his foreskin and his glans.

Is that even possible?  There is no drawstring!  How does the crack stay there?  Not having a little foreskin pouch of her own, newFNP frankly just does not understand.  But if it's true, that is gross.  And apparently very dangerous.  And yet another reason to add to the 'con' column when considering crack smoking!

Dr. Dual-Ivy-League-Degrees had a good point about this one - the most important question in the history is often, "What do you think might be causing this?"

Your cheating heart

iWhen newFNP was in grad school, she had a dear friend - who shall remain anonymous - who visited an out of town ex-boyfriend under the pretenses of rekindling an old romance.  Upon arrival, it became clear to her that she was not going to having any knight in shining armor moments with this guy.  Why?  Because despite the fact that she flew some distance to see him, he had made plans with another ex-girlfriend for the same frigging weekend!  When her pal called, incredulous, and related the story to newFNP, newFNP came up with a plan.

"OK," newFNP said, "While he is at out of the house, go to the grocery store and buy some frozen fish.  Put it under his couch right before you leave.  By the time he realizes where the hideous smell is coming from, you'll be long gone and his couch will stink to high heaven!"  

Evil?  Sure.  Fantasy revenge plot?  Definitely.  NewFNP's friend, however, is far too kind to engage in such behavior and simply changed her flight home for an earlier departure and removed this guy's name from her cell phone.

Imagine, then, being 32 weeks pregnant and discovering that your husband of twenty years, with whom you have four daughters, has not only been with another woman for three years, but has fathered two more children by her!  When you come into newFNP's office with that, newFNP is very sympathetic.  

NewFNP knows that research shows that a two-parent family is better for children.  But it seems like a tough pill to swallow to expect someone to stay with a lying sack of shit just for the sake of the kids.  Is it too much to ask people to just grow a pair and respect their relationships?  If people have decided that outside relationships are cool, then great - have at it.  But that is not the understanding this woman had regarding the expectations of her marriage.

She gave him one month to decide what he wanted to do, which is about 30 days, 23 hours, fifty-nine minutes and fifty-nine seconds more than newFNP would have given him before his boxer shorts, shaving cream and nose hair trimmers were out on the front lawn.  

But this woman is in a real conundrum.  They have a $3400/month mortgage payment.  Fannie Mae, Freddy Mac, Indy Mac!  Do you hear newFNP, you fuckers!  Do not give mortgages to people who cannot afford them.  And $3400 to live in the shitty area where newFNP works?  Does the house come with bars on the windows and an alarm system and an armed guard and a pit bull and a rottweiler?  No fucking thank you.

NewFNP never ceases to be surprised when her patients tell her about their crazy expensive mortgages.  How in the hell do her patients afford houses when newFNP can barely afford her 1-bedroom apartment?  It kills her every time.  Granted, her patients did not spend nine years in college and grad school but still.  Fuck!  NewFNP wants a house and a pool and a dog.  Damn!

OK, back to the patient.  Obviously, she was distressed.  She is 32 weeks pregnant and has lost five pounds in the past month.  She was crying as she recounted the tale to newFNP.  NewFNP asked her what she wanted.  She replied that she wanted him to tell their daughters why he was leaving and then she wanted him to leave.

Forever attempting to be culturally aware with her Latino population, newFNP said,"Well, you can always put hot sauce in his underwear."  She laughed - hard.  Sometimes it just helps to imagine it. 

If anyone needs break-up revenge advise, please, newFNP is here to help. 

T minus 36 days

NewFNP is a broken frigging record.  She is burnt out.  No, she is charred.  She is unrecognizable.

She has, however, had some lovely encounters lately that have re-affirmed her love for nurse practitionering.  Her post-partum patient who was thrilled to introduce her newborn baby to newFNP, who had done the vast majority of her prenatal care, and who told newFNP that she wold help care for newFNP's baby when she finally got around to having one; the physical exam with a lovely woman who gave newFNP a big hug in the hallway and could be heard telling other staff members how happy she is with the care she receives at the clinic; the mom who entered the exam room so angry after having waited for hours to have her daughter's ear examined who left with questions answered and hope that her daughter's chronic condition will be solved; the overwhelmed patient for whom an IUD is a real life-saver.

She was so thankful to host nhFNP and nycPNP a couple of weeks ago and not only because of the crazy delicious tapas and wine!  Theses ladies graduated with newFNP three years ago.  Both are on their second jobs - various aspects of their respective first jobs having chewed them up and spit them out.  Both are happy and thriving in their new positions.  One even presented her work at a major conference recently.  

If newFNP were to present her work somewhere, it would be like an avant-garde show involving lots of crying while in the fetal position, some throwing up, and monkeys throwing loads of crap at her.  That is not how newFNP wants to have her work represented.  

NewFNP is struggling with the thought of leaving community health.  She takes a lot of pride in her work and she has a real love for her patients.  But the utter lack of a system is killing her.  Perhaps she will be able to maintain her sanity if she is only entrenched in the mire of her clinic part-time.  

And, just as importantly, she can't really leave full-time community health practice... whatever will she write about if she leaves entirely?!?!

Thirty-six work days until she can go.  Thirty-five if she gets a UTI or an otitis or something.  Nothing serious, of course.  Just something a little trip to the day spa would cure!