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.