Pura vida

NewFNP has been home from Costa Rica less than forty-eight hours and she already wants to go back.   

Lost in translation

Misspelling is common is newFNP's clinic.  Chlamydia is tough to spell.  Gonorrhea is no picnic either.  And don't even get newFNP started on Kwashiorkor or borborygmi.

Generally, however, the misspellings have an obvious translation.  Thus, newFNP was thrown for a loop when she saw a chief complaint of "Cephalus Check."

Cephalus???  What happened during that hunting trip when Eos kidnapped him that he needs to come to a free health clinic for a check up?  

But seriously... cephalus?  Was newFNP asleep for that lecture?  Is that a condition newFNP missed?  It is hydrocephalus?  Shouldn't this patient be at a neurologist?  

What a sophisticated misspelling it ended up being.  

The patient was requesting a test for syphilis -- just regular old syphilis.   But newFNP likes the way this front-desk staffer was thinking!  Use the 'ceph' root.  Give newFNP a little taste of the 'ph.'  Hell - make her think about mythology during a humdrum clinic day.

That's right, yo, you gotta class that shit up a little bit!

Dementia praecox et Cocoa Brown

Would it come as a surprise to anyone if newFNP disclosed that Cocoa Brown had serious mental illness?  It pains newFNP to see her suffer.  

Cocoa Brown has schizophrenia and boy does she ever struggle.  When she feels like she needs a break from the world, she goes into the emergency room and tells them that she is suicidal.  She has attempted suicide in the past, she is marginally compliant with her anti-psychotic because she frequently runs out before she makes it to the pharmacy for a refill, she has a history of drug abuse, she is precariously housed and, frankly, if she wasn't in psychiatric care, she would likely be actively suicidal again.  

Cocoa Brown has also developed urinary incontinence, perhaps as a result of her anti-psychotic, perhaps her weight, perhaps a combination of the two.  

Do.  Your.  Kegels.  

During Cocoa's most recent inpatient mental health stay, she fell asleep in the day room and had an accident.  To hear her tell it, a nurse kicked her chair and gave her a bit of shaming about the accident.  Cocoa Brown described the conversation that subsequently ensued.

Cocoa Brown replied, "What the fuck are you waking me up for to tell me that.  Everybody knows I can't control that!"

(NewFNP imagines that the nurse pauses at this point, wondering what her next move should be.  Cocoa Brown, however, is undeterred.)

"You don't wake me up for that!  You wake me up when it's fucking time to eat or take meds, but you don't fucking kick my chair and wake me up for that!"

(Amen to not missing a meal.  On a roll now, newFNP imagine Cocoa Brown pointing an index finger at the nurse.)

"The next time you wake me up for something like that, I am going to knock you the fuck down!"

Lest anyone think that she is not serious, may newFNP remind you that Ms. Cocoa Brown previously attacked an ex-partner with an exposed-nail ridden board.

NewFNP could have given her a lesson about behaving properly.  Instead she simply said, "Cocoa, I hope to never hear those words directed at me."  To which Cocoa replied, "Aw, newFNP, you know I'd never say that to you."  

Whew!

However, the scenario does bring to mind several salient points:

- unlike Cocoa Brown, newFNP would like to be awakened if she is dozing off in a puddle of her own urine.

- mental illness causes people to behave in unpredictable, non-normative ways.

- mental illness has a devastating effect on people's lives.

Cocoa Brown will never have a normal life.  Her schizophrenia will likely continue to affect her life in negative ways.  She is poor, she is socially marginalized, she has not benefited from vocational therapy or social rehabilitation.  The internal and external worlds in which she lives are very different from most people's. 

But newFNP loves taking care of her -- as much as she can.  Pill refilling, blood pressure monitoring, syphilis treating, and in offering a friendly and peaceful exam room where Cocoa can just be Cocoa.

Guiding Light

In newFNP's dreams, her clinic would utilize the in-speculum pap light.  What a world of difference those lights make.  

Alas, despite her pleas, newFNP's clinic employs the bulky swan-neck pap light and right now newFNP's clinic is experiencing an epidemic of pap light demise.  The storage closet is a pap light graveyard.  Is it simply an issue of a burned out bulb?  Did the lights just collectively decide to throw in the towel after years of vag lighting?  NewFNP doesn't know, but what she does know is that she needs to put some light on the subject when it's pappy time.  

Twice today, newFNP sat down on her rolly stool and went to grab the light only to discover that it wasn't in its corner.  (One may wonder what this says about newFNP's powers of observation that she was already ready to roll before she noticed that the light wasn't there.)

The first time, newFNP tasked her MA to scrounge up a light.  

The second time, newFNP said "fuck it," put the speculum in place and grabbed the otoscope from the wall, aimed it towards the center and identified the cervix.  After all, it's not as though the vagina is some vast cavern and one needs some type of spelunking light by which to guide the journey.  The anatomy basically regresses to the mean.  Thankfully, her patient today was no anatomical outlier.

NewFNP is nothing if not handy in a pinch.   

A very happy 4th anniversary

Today is the 4th anniversay of newFNP. She is hardly new anymore, is she?

NewFNP's anniversary week has been graced by a long-time patient welcoming a new baby girl, another long-term patient hospitalized and dying, and by the always exciting return of one Ms. Cocoa Brown. A story for another day.

Because today, on her 4th anniversary, newFNP is dolling herself up for a celebration. She is so appreciative that her cousin and his fiancee scheduled their wedding on such a special day.

To her favorite ice climbing, engineering, post-doctoral molecular geneticizing couple - mazel tov.

Milk it does...

Several weeks ago, newFNP stepped in to do a well child exam on an 18-month old well known to her.  NewFNP takes care of her grandma (scleroderma), her grandpa (missing frontal skull bone after 2 infected craniostomies following a truck tire exploding and striking him in the head) and her mother (21-year old with uncontrolled hypertension on 5 daily medications including clonidine with a history of methamphetamine use, now abstinent).  

When newFNP saw this child's hemoglobin, her heart sank.  It was 4.9.  The child's skin had an unhealthy grayish hue.

Repeat it, newFNP instructed her MA.  Her blood was pinkish.  The repeat hemoglobin was 4.5.

Shit, newFNP muttered.

Is it leukemia?, newFNP asked her colleague.  It's leukemia, he responded.  4.9 is fucking low.

NewFNP went with the grandparents into the exam room as the young girl's mom was at work, where she is six days per week.

NewFNP told them that she needed to send the little girl to the hospital and that she was concerned about leukemia.  

Never before has newFNP been on the verge of tears in an exam room.  But she knows this family and she knows that they have been to hell and back and that they all still suffer and she loves taking care of all of them -- that is one of the joys of family practice.  

She called the patient's mom and told her to come immediately to take her daughter to the emergency room.  The patient was crying, her mom was crying, her grandma was crying.  NewFNP was barely holding it together.

Hours later, newFNP spoke with the patient's mom to see what had transpired.

What had transpired was the this little girl was drinking upwards of 50 ounces of milk daily.  She didn't have leukemia -- she was a lactoholic.  She was discharged from the ER with iron.  No transfusion, no nothing.  Follow up and repeat the CBC in 2 weeks.  NewFNP couldn't believe it.  

4.9.  From milk!??!!**

Her repeat CBCs have been greatly improving, her pallor has disappeared and she appears to be not at all suffering withdrawal from her milk dependence.

Pass it on.

____________________

**When kids drink too much milk, they don't eat iron-rich foods -- or much of any foods for that matter -- and they may have intestinal irritation that causes asymptomatic blood loss in the stool thus causing anemia.   

Broken heart

NewFNP was awaiting the EKG results for her 20-year old methamphetamine treatment seeking patient when her awesome lab supervisor came out and handed her this:

NewFNP was a little stunned.  Q-wave in III.  rR' in V1-V3.  A 20-year old guy.  "What the fuck," newFNP thought to herself.  Her lab supervisor helpfully offered that the young man had a large vertical scar to his chest.

Ah, cardiac surgery.  If newFNP were a cardiologist, she might have been able to identify the EKG changes immediately.  Alas, she is not so she was left to question the young man as to his cardiac history.

She asked him to tell her about his heart surgery.  He replied that he had never had heart surgery.  Hmmm.  NewFNP then inquired as to the etiology of the large suprasternal scar.  

"Oh yeah," he replied.  "I had a heart transplant."

"A heart transplant??!" newFNP responded and then inquired if he was taking any medications.  He replied that he was not, leading newFNP to deduce that he was likely mistaken as to the nature of his surgical procedure.  

She asked him why he may have had heart surgery as a child.  He was unable to tell newFNP.  

NewFNP conducted his cardiac exam which was -- not surprisingly -- abnormal.  His pansystolic murmur over the aortic region obliterated S2.  His murmur over the pulmonic region was palpable.  The other murmurs were less extraordinary.

At this point, newFNP was stumped.  In retrospect, she should have put it together.  Pulmonic stenosis.  Childhood cardiac surgery.  But newFNP has never seen anything like this and she just couldn't put the pieces together.  

Thankfully, the young man's dad showed up to the clinic and explained that the patient had Tetralogy of Fallot repaired when he was 18-months old.  Prior to the repair, he had multiple Tet episodes leading to numerous hospitalizations.  The surgical repair was delayed due to a lack of health insurance.  As a result, he spent his first 18 months lacking oxygen.

It is fair to say that this young man is not bright.  In her interactions with him, newFNP often sensed that his IQ was quite low.  Now she had a reasonable explanation as to why.  The bummer is that because his IQ is so low, he cannot appreciate the consequences of his actions like others might.  

For instance, methamphetamine is cardiotoxic.  His heart is repaired, but not normal.  This combination might give someone else pause.  It was clear that this young man did not understand the potential impact.  His parents understand though.  It was difficult to see the sadness and desperation in their faces as their son averted his eyes and spaced out during the visit.

He is set up with a cardiology referral, an addiction treatment referral and a list of clinics where he can have neurocognitive testing completed and get referred to vocational education.  He still doesn't understand why these appointments are important.  He has other things to worry about.  His girlfriend wants to have a baby.  His friends want to go out and party.  He has no concept of consequences.

Heartbreaking.

When you're sliding into first...

There are often times when the chief complaint truly misses the nuance of what the real concern holds in store.

For instance, a chief complaint of diarrhea in a child is not so common, not so nuanced, not so big of a deal.  

(As an aside, newFNP had a pediatrics professor who invariably pronounced the word diarrhear, which so brought glee to newFNP and BostonFNP during a long day of dry lectures-- and it still does to this day!)

But what if diarrhea is not just diarrhea?  What if it is encopresis?  Well then, you're in for a hell of a different appointment.  

The history went something like this: the six year old boy was toilet trained, but then he started soiling.  When he's with mom, she has him wear diapers, even to school.  When he's with dad, he is instructed to go commando so that he is forced to "learn to control himself."  Both interventions wholly unacceptable and antithetical to appropriate treatment.  

To be fair, this is in part the clinic's fault.  He had been seen twice before for the same problem, had received minimal guidance and had no improvement in symptoms.  No big surprise there.  It's a confusing diagnosis for parents.  It's tough for primary care providers to give diagnoses such as this the appropriate care given that it involves greater than 10-15 minutes, education from the provider and counseling from an actual counselor.  

What makes this even more difficult is when the kid's father is intoxicated in the exam room and when the kid's mom is absent - both from the appointment and largely from his home life as she works and spends an extraordinary amount of time volunteering at church.  It was clear to newFNP that the kid was used to his dad being drunk when she watched him call his name and gently slap his face in order to rouse him when she called them in from the waiting room.

All throughout the encounter, newFNP was concerned about neglect.  But the kid was clean, he was growing appropriately, and he related well with newFNP and with his father.    His future might not be the brightest given the family history of alcoholism and the poverty, but poor alcoholics raise healthy thriving kids so we'll have to institute a prospective study to see where this kid goes.  NewFNP decided that it wasn't neglect - that it was ignorance regarding the problem and lack of support.

NewFNP gave the appropriate education, both verbally and in written form, instructed the father that both the diapers and the sans undies must stop A.S.A.F.P., ordered an x-ray, prescribed Miralax and toilet times, and hooked the family up with free counseling.  This took about 40 minutes.  

Worth it.  They showed up to their counseling appointment the next day and have follow-up scheduled.  

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.