Fat

NewFNP is back from the most restful time she ever had in the state where she attended graduate school.  Her school years there were full of studying and bad weather and really bad weather, whereas her Independence Day long weekend was full of tranquility, mild weather and relaxation with grad school pals.  

And now she's back and has questioned more than once why on earth she lives in the urban jungle when tranquility and waterfalls are available to her??  Ah yes, proximity to Barney's.

Her first day back in clinic was also her first day with her second ever student from her alma mater.  It was a day filled with tough patients.

There was the 2-month old infant who would not make eye contact.  Is it a retinopathy? Is it an early indicator of autism?  NewFNP isn't sure.  Ophthalmology consult!  

Then there was the Mirena that twice fired prematurely with no assistance form newFNP.  NewFNP felt like a nervous lover - and in front of a student!  Eek.  Her student later asked newFNP if that was a normal amount of nervousness for an IUD insertion, to which newFNP replied, "For newFNP or for the patient??"

Then there was the 20-year old G1P0 who was far more interested in picking at her thick French tips than participating in her prenatal care.  

And finally there was the 19-year old G1P0 with a BMI of 55.5.  No joke.  She is 5-foot-1 and 294 pounds at 36 weeks gestation.  She was 254 at her first prenatal visit.  

NewFNP frequently reads lay articles and medical journals with stories and studies and statistics about the obesity epidemic.  Fourteen is the new ten.  Children are at risk.  This will be the first generation to die earlier than previous generations because of the effects of obesity.  The south is fat.  

OK.  NewFNP gets it - as a nation, we're fucking fat.  

But please, please.  Tell me just what in the world providers are to do?  These are the avenues newFNP has attempted with her portly nullip: 

1) just the facts, ma'am (health of mom and baby, labor complications, gestational diabetes risk); 

2) supportive listening and encouragement (yes, it's hard to change our habits but you're doing this for your baby and yourself; yes life has dealt you a rotten hand -- let's change that for you and your baby!!);

3) stern lecturer (this has to stop -  we are talking about the health of you and your child);

4) Richard Simmons (have you tried our prenatal yoga class??);

5) throwing the fruit punch in the trash.

And this is with one patient. 

Obesity is a public health problem.  This is not a problem that individual providers can address on a large enough scale to prevent and treat obesity.  It's not that newFNP doesn't talk to her patients about their weight - she does.  She talks to normal weight patients, underweight patients -- all 3 of them, and overweight patients about their weight.  But that isn't enough.

Children are fed trash in public schools.  WIC -- for all its great work -- gives away coupons for trashy foods.  Parents give in to children's pleas for junk food.  Poor urban areas are full of fast food options and liquor stores.  Poor urban areas are not safe for outdoor play and exercise.  Fruits and vegetables are expensive.  

So what are we going to do?   NewFNP is open to suggestions.  

-------

Congratulations and love to BostonFNP and BostonJD.

OB, oh boy!

It pleases newFNP that she continues to experience new challenges in clinic.  Otherwise, the work gets a little too rote.  Thankfully, newFNP's prenatal practice has been supplying her with a couple of not taught in school-style scenarios.

In the past week, newFNP has had five patients on the verge of labor.  Generally what happens is that newFNP educated patients on when they should go to labor & delivery and, with the exception of her eighth-grader in labor, that is what happens.

Not so much this week.  One patient presented for her repeat c-section, ineligible for VBAC due to her first c-section being conducted vertically, checked herself into the hospital and then checked herself out, only to drive to another hospital where she had the cesarean.  Another patient presented to her c-section appointment because her fetus is stubbornly breech, only to be turned away and instructed to return in a week.  NewFNP scheduled this c-section according to the hospital's protocol for breech position, not according to her own whimsy.  Whatever.

Finally, not once, but twice in the past week, newFNP has had patients present to the clinic in labor.  Her most recent patient (G3P2) was three days post-dates and had a urine dip that screamed UTI and dysuria to boot.  To top it off, she was contracting every three minutes in the exam room.   She was laughing through the contractions and they were only lasting about 20 seconds.  NewFNP, however, was not laughing.  

Here was newFNP's conundrum.  It was simple really: treat the UTI with some Rocephin and then send her to labor  delivery or just send her to labor & delivery.  Truly, newFNP thinks that either way would have been fine.  But she prefers to TCB in the clinic, rather than shuffling her patients off with business left to take care of.

NewFNP called her Family Practice MD colleague who advised her to do a vaginal exam to assess for cervical dilation and effacement, give the Rocephin based on what was going on all up in that and go from there.  

Here's the problem: newFNP doesn't totally trust her cervical exam.  She just hasn't done enough of them on pregnant ladies in labor.  Sure, if she could put her head in there with a miner's light, she could easily tell if that action is dilated.  But on a 232-pound lady who is 10 months and three days pregnant, the exam is not so easy for newFNP.  Nonetheless, newFNP strode back to the room, sterile gloves in hand, and proceeded to examine the hell out of that cervix.

And folks, that was a good cervix to assess.  NewFNP felt 5-6 centimeters of dilation and nothing but head.  NewFNP's patient, shocked, just kept laughing through the contractions.  NewFNP called her MA to deliver the Rocephin, called the prenatal coordinator to deliver the taxi voucher as her patient had driven herself to her clinic appointment, had her call her truck driving husband and ask him to turn that action around, and sent her on her way.

She gave birth to a healthy 9-pound girl a few hours later.

The fifth patient just went to the L&D floor as directed.  

So, all in all, 20% of these ladies had labors that went down as newFNP had anticipated.  Doesn't matter.  All that matters to newFNP are healthy moms and babies.  

Girl, you'll be a woman (far too) soon

NewFNP is just going to put her bias right out there: if not a single teenager ever got pregnant again, newFNP would be just fine with that.  Sure, having a baby when one is in the 10th grade is not the end of the world.  It doesn't absolutely mean that one will never, say, graduate from high school or attend college.

But it sure as shit makes it more likely.

NewFNP concedes that it is utterly possible that the 16-year old sitting in her exam room, pregnant with twins, was not necessarily college-bound to begin with.  Most of her patients do not go on to college, but newFNP makes it a practice to plant the seed in her pediatric & adolescent patients that they have options and that college is a very good one indeed.  NewFNP recognized her patient's mom as one of the women who regularly sells champurrado outside the clinic from an orange Igloo container.  Maybe college has never been thought of as a possibility for her children, never been discussed in the family.  Maybe grandchildren will bring more joy than will the pride associated with watching your child succeed academically - newFNP just doesn't know.

NewFNP moved between the medical and social histories with this patient.  Tenth grade.  Lives at home.  Planning to continue the pregnancy.  Medical history insignificant until now.

When she inquired as to the father of the twin fetuses, her patient replied that he was involved.  

Great - that is a good start.

"Is he in school?," newFNP inquired.

"No," her patient replied, eyes averted.

"What is he doing?"

"He's working."

"How old is he?" newFNP asked.

"Twenty-three," came the sheepish reply.

Somewhat shocked, newFNP turned to her patient's mom and asked her what she thought about this.  She replied that she thought her child's Casanova was a good guy.  

NewFNP almost fell off her rolly stool.  It is a situation such as this in which newFNP imagines herself going vigilante in her hypothetical parenting world.  This is a man and a girl.  This is statutory rape.  This is one of the many reasons that newFNP is a huge fan of the birth control pill, the IUD, even the shot (of which, truth be told, newFNP is no real fan).

Her patient's mom told newFNP that she had instructed her daughter to be careful.  Be careful?? Has this mom never met a twenty-three year old man before?  Because newFNP has, and she knows that they are horny motherfuckers.

NewFNP referred the girl to high-risk OB and to pregnancy case management.  She reminded her that quitting school was not an option, that she would, in short order, have two children to support and that those children would look to her for guidance.  

It wasn't one of those encounters that newFNP walked away from feeling hopeful about the future or inspired by her work.  

She just felt sad.  And disappointed.  And angry.  At herself for not being a better counselor, at the mom for not helping her daughter get contraception and for condoning the relationship and at the guy for dating a high school student.  

Out of the rut, follow the gut (instinct, that is)

NewFNP has been caught in the hum-drum of sameness at clinic.  Paps, prenatals, diabetics, URIs.  These are the norm of clinical practice, but the routine gets a little drab.  Don't get newFNP wrong - she doesn't want to work in a emergency room, but she does like a little change-up here and there.

She got it.

NewFNP was doing an abdominal exam during a well-adolescent visit.  The kid was fourteen, had no medical history to speak of and had no complaints.  Nonetheless, the instance newFNP palpated his belly, her internal alarm sounded.

This young man was not especially skinny - just average with a smidge of baby fat.  Had he been thin as a rail, newFNP would not have been so startled when she felt his abdominal aorta pulsating very prominently and pulsating a full two finger breadths to the right of the umbilicus.  She attempted to measure the aorta and estimated about a three-plus inch width.  

NewFNP spent a while running this through her mind.  She didn't feel a mass and she could not determine the direction of the pulsation.  The only thing of which she was certain was that this exam did not feel right.  

She got Dr. Dual-Ivy-League-Degrees to consult -- she agreed that it was an unusual exam.  

Maybe this is normal for him, but son-of-a-bitch if it's an aneurysm.  What are the odds at fourteen years old?  Un-frigging-likely.  Nonetheless, newFNP trusted her gut and sent him and his gut for an ultrasound.  She is anxiously awaiting the results.

Dress code violation

The inappropriate t-shirt trend has followed newFNP to the research clinic.  The reach of the inappropriate t-shirt is, apparently, far and wide.

When newFNP saw her patient filling out forms in the waiting room, she did note that his shirt said "F.B.I." across the chest.  NewFNP naively thought that this gentleman seeking to participate in a research study about methamphetamine addiction was perhaps showcasing a touch of irony.

Not so much.  Upon closer inspection, newFNP notes that underneath the "F.B.I.", the shirt read "Female Body Inspector."  Classy.  The only female body part newFNP will let this fellow inspect is her stank eye.

But the self-appointed Female Body Inspector had nothing on the wildly inappropriate t-shirt that another research participant was wearing.  This shirt was a walking advertisement for the metal band Cloven Hoof.  This shirt featured a graphic of a mullet-man orally pleasuring a woman.  Charming.  NewFNP gets it - figuratively - and she is none too pleased.  

When newFNP gets dressed in the morning, she does the usual mirror checks: no VPL, no muffin top, no boob overflow, no totally fucking offensive t-shirt.  Check, check, check and most definitely check.

I mean really.  Cloven Hoof?  Cunnilingus?  What makes someone purchase such a shirt?  And then what possesses someone to wear that shirt to a medical clinic?  

Yuck.

Action!

What's up, nurses?  We're fucking famous, that's what.  Or maybe nursing leaders are in cahoots with the entertainment industry to make nursing appear to be a more attractive profession in the face of a horrible nursing shortage.

Not one, but two new TV shows with nurses as lead characters!!  Showtime's Nurse Jackie and TNT's HawthoRNe.  

NewFNP's hope is that the TV shows will do nursing justice and that the characters will be interesting and complex and funny and smart.  It's newFNP's fear that a recurring dynamic is going to be the physician-nurse tension as is showcased in the HawthoRNe commercial.  That dynamic is tired.

NewFNP's money is on 'Nurse Jackie'.  It has Edie Falco, it's on cable and on the same network that brought us 'Weeds' and 'Huff', it has a nursing student character and it appears to have been thoughtful in its character development.  

And if the show's writers need any technical assistance with the science and art of nursing or with story line development, newFNP shall avail herself to them!

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.