It's not you, it's newFNP

NewFNP needs her head examined.

She gave notice at her research position and is going back to full-time community health. It's not as crazy as it sounds, she supposes. NewFNP has been spending a lot of time lately thinking about what kind of FNP she wants to be. (This is certainly something that her name brand nursing school did not teach.) High atop that list is that newFNP wants to be a community health practitioner. There certainly is a pride one feels when working in and for an underserved community.

NewFNP also wants to be a good teacher, a supportive listener, a knowledgeable medical practitioner, the type of person who says yes more often than she has in the past. This may be far more than newFNP can realistically achieve, but it is important to articulate and strive towards one's goals.

As such, starting early April, newFNP will be back in the thick of it. She hopes that she won't burn out so quickly this time around and that she'll have a lot of interesting tales to share.

That being said, she will miss working for her brilliant and hilarious research physician and her talented and creative research assistant. It is so hard to let people down.

Soda - two thumbs down

NewFNP was at the gym yesterday, reading the NYT whilst stationery biking. It's not her favorite workout, but yesterday was a day during which newFNP had to kill two birds with one stone. Thus, NYT and exercise together -- it's like church for newFNP.

The Week in Review section had a below-the-fold article about taxing soda written by Mark Bittman, whose bread recipes tend to be quite good, but whose sugar cookie recipe leaves something to be desired. Clearly, no manufacturer of any product is supportive of a tax on their wares, especially to the tune of 1 cent per ounce and when your product is being blamed as a component (and not an insignificant one) of the obesity epidemic. The industry quotes against such a tax were so transparently douchey, especially the one from one Mr. Derek Yach of PepsiCo who wondered if a tax on sugary food might make things worse by leading to an increased consumption of fat.

It should come as no surprise that newFNP supports such a tax. (She supports taxes on cigarettes as well. If marijuana were to become legalized, she would support a weed tax.) Soda has no nutritional benefits. Okay, okay, it has sugar. But overall, while tasting good, it is a piece of dump nutritionally speaking. When newFNP counsels newly diagnosed diabetics - something she does with alarming frequency - one of the first points she makes is that soda is a no-go, a killer, absolutely a never on the diabetic food pyramid. She believes that using the public health model that targeted cigarette consumption is a reasonable approach. After all, cigarette consumption has decreased significantly over the past few decades.

The article got newFNP thinking that there are other ways to decrease soda consumption. In newFNP's clinic, many, many of her patients receive food stamps. A quick trip to the national food stamp program website states quite clearly that the goal of the program is to help low-income families buy food that supports good health. Clearly, soda should not be on that list. Food stamps are a government program and the government already dictates some exclusions from the food eligibility list. For instance, alcohol is excluded, yet non-alcoholic mixers are not. Cigarettes are excluded. Flaxseed oil is excluded, yet cooking wine is okay. Hell, you can get bows and arrows with food stamps if you are lucky enough to live in Alaska!

If newFNP were asked to update the eligibility list, she would exclude all non-dairy sugary beverages. Good-bye Sunny D! You're not fooling anyone! See you later Orange Crush, you asshole. No one needs you! And no one would be about to do the Dew with food stamps.

But newFNP wouldn't stop there. No Hot Cheetos or any kind of chips. Knowing that food stamps and health are political issues, she might compromise and let Sun Chips or Baked Lays sneak by. No candy. No sugary cereals. No Lunchables. No Hostess, not even the delicious chocolate doughnuts that are so yummy on roadtrips home from snowboarding.

Yes, nutritious foods are expensive. Fresh fruits and veggies go bad if not eaten in a timely fashion. But frozen veggies don't. And if one's cart isn't piled high with a bunch of shit, the food stamps might go a little farther and actually work toward the program's goal of supporting healthy nutrition options in poor families.

And then move on to the schools. No soda dispensers and quit cutting recess and P.E. time. Seriously people - don't just have kids run the mile. Throw a kid a bone and help them to find a physical activity that they like, that they'll do for their entire lives. How about mat pilates P.E.? Hip hop dance P.E. class? Weight training. Not square dancing. Repeat - not square dancing.

Michelle Obama, if you're reading this, newFNP is here to help.

It's all about the Hamiltons, baby!

NewFNP realized that she censors herself and that is so weak. So fuck it, let's talk about poverty.

It feels a little like a Seinfeld episode to say "not that there's anything wrong with it," but perhaps it is not entirely transparent that newFNP thinks that there is nothing wrong with being poor. That being said, there is also nothing wrong with wanting to not be poor either.

Poverty sucks. Urban poverty super sucks. Almost five years into practice, newFNP continues to be struck by the difficulties experienced by her patients -- difficulties truly unknown to her. Urban poverty often means gangs, school failure, cockroaches in ears, overcrowding, poor nutrition, medical debt, precarious housing, stress.

NewFNP grew up kinda poor after her parents divorced. Her dad often didn't pay the $400 child support payment that was to be shared between newFNP and broFNP. The first duplex in which we lived post-divorce was in the shadow of the interstate. But newFNP's mom had a college education and newFNP very frequently heard the mantra of the importance of a college education. And this was when she was in third grade. So while newFNP's family was financially poor, she had some socioeconomic buffer based on her mom's education.

NewFNP's patients, by and large, have no such buffer. They often live day to day, hand to mouth. Daily life beats them down enough that there is very little future orientation.

A patient today, a 30-year old unemployed woman with three children, eight year-old rippled breast implants and a tubal ligation, was interested in A) reversing her tubal in order to have another child with her boyfriend of four months and B) getting a do-over on the implants. Yes, get those rippled things switched out before something bad happens, absolutely. Yes, your health is worth the $5000 or whatever the new boobs cost. Reversal of tubal ligation? Likely very expensive and likely not covered by one's state-funded insurance program.

But are these out of pocket expenses financial priorities? Does she have Suze Orman approved savings? Do her children have college savings funds? Is it a universal truth that all parents want their children to succeed and be financially stable?? Does newFNP have any fucking business in encouraging her patients to think about such things or even thinking these thoughts in the context of patient care?

NewFNP doesn't know, nor is she any kind of sage financial guide. Lord know that if newFNP had an extra three grand laying around, she would have a Bertoia Bird Chair faster than you can say sham-wow!

But newFNP's gut says that even the least educated, financially marginalized champurrado vendor would prefer that her child be a teacher than sell shoes on a corner. But how does she help her child get there if she herself has no idea, if she's illiterate, if she hasn't set foot in a classroom since the 7th grade?

Or what is a family teaching their children if the parents don't work, if they hang out and watch TV and have state aid? Like, if the goal is state aid, end of story? If there are four fathers of four children?

(Is newFNP completely losing her liberal credibility for even thinking such things??)

There is definitely an argument that goes like this: NewFNP, just shut the hell up and see your patients for their ear infections, et cetera et cetera.

Then there is the argument that goes like this: People need help and they often come to clinic for more than just what their chief complaints might have one believe. And people who impact the lives of others do more than the bare G.D. minimum.

Perhaps she should adopt the former approach when she notes feelings of judgment towards a patient, as she did with the BTL-reversal wannabe today. Providing good medical care is, after all, a good outcome in and of itself.

But helping to teach someone avenues through which to escape poverty - that seems like an okay thing to do as well. Is that just too pie in the sky? Is it classist? Is it even a realistic goal given the constraints of clinic? Ah, fuck it. Who knows.

Yippy-kay-yay!

NewFNP's mom died twenty-two years ago today so after a busy day at clinic, newFNP was feeling a little gloomy on the quiet ride home.

Then she saw a gentleman riding a horse down the sidewalk along a very busy thoroughfare in her very urban city and broke into laughter. He was heading west, then turned to head north down another busy street. Adios, partner.

Who wouldn't feel better?

Potty mouth

NewFNP had a completely fucking bizarro day at clinic today.

For starters, her first two patients -- both new to clinic, of course -- had schizophrenia. The second one also had a wonky eye.

Then there was the chlamydia patient -- the first chlamydia of the day. The first patient was pretty normal. However, he had genital warts that were growing in perfect projectile symmetry on either side of the glans, conjuring images of a caterpillar. NewFNP is a sucker for symmetry and, in fact, has a real aesthetic bias against asymmetry and has, frankly, never seen warts grow in such mirror images of each other in non-touching skin.

Then she had a syphilis patient and began to wonder if she had stumbled into the mental health/STD clinic.

Then she saw what felt like another 7 million patients when she came across her second chlamydia patient of the day: a 17-year old primigravida who is 38 weeks and 4 days pregnant and who had her first prenatal visit last week. Can newFNP interest you in Azithromycin?? Open wide.

Then she saw five other patients when her clinic manager and the brand new RN came in at 5:15 and asked if she would please see another patient, to which newFNP replied, "You have got to be fucking kidding me." And then she saw two more patients.

NewFNP's mouth is absolutely going to get her in trouble one day. She needs to reign it in. In her defense, however, newFNP did not have even a 10 minute break today. She peed once and texted a patient her lab results from the bathroom.

What newFNP really needs is to work in a high-functioning community health clinic with the gestalt of a tattoo shop. Barring that, though, she really should learn to just shut the eff up.

S-A-TUR-D-A-Y! Clinic!

When newFNP was in public health school and was discussing access to health services, she recalls evening hours and weekend hours being touted as one option the system provides in order to increase access to care. All these years later, it is exactly those two things that newFNP likes the least about her schedule.

Nonetheless, as she was seeing patients yesterday during a very busy Saturday, she was reminded of a few lessons in patient care.

It is not uncommon that when newFNP asks a patient how they are, they answer "Mal." Bad. Truth be told, it is newFNP's least favorite way to start a visit (although she completely acknowledges that this reaction is completely her own baggage). Can't we just pretty please have a moment of pleasantries before we delve into the nitty-gritty of the visit? Alas, newFNP has found that when people answer in such a way, it generally is because they are doing badly and probably have taxed each and every ounce of their resiliency reserves to the point of complete bankruptcy such that they can't even fake it anymore. It is always a tip off to newFNP that she must screen for depression.

It is also not uncommon that as patients are waiting to be seen at newFNP's clinic, the waiting room is frequently SRO. It is loud. It gets dirty. The temperature is never just right. It sometimes smells not-so-fresh. The time spent in that room can accumulate into hours. Being a competent and kind provider goes a hell of a long way to ameliorate the effects of that hellish wait. As she was finishing up a prenatal visit yesterday -- one which truthfully felt a little rushed to newFNP -- her patient told newFNP, "Can I see you again? I like the way you take care of me." It made newFNP feel proud and guilty at the same time, feeling good that the patient felt well cared for and feeling mal knowing that this patient didn't really receive the best care newFNP could have offered her.

It is really wonderful to take a moment to reflect upon these lessons. And it is so much sweeter as newFNP reflects upon them while in her dining room, drinking French Roast, Sunday NY Times by her side, decidedly out of weekend clinic responsibilities.

Pop

NewFNP is hard pressed to identify anything that separates her from her patients more than does diet, culturally speaking.

One of newFNP's physical exam preventive health screening questions is: Do you eat fruits and vegetables every day? The answer is generally no. She also asks: Do you drink soda? This answer, in contrast, is generally yes.

But the answer is not so commonly yes to the tune of 60 liters of soda daily. Sixty liters seems, shall we say, excessive. That level of consumption constitutes approximately 2500 calories per day and 100% of them in nutrient-void carbohydrates. In addition, it's doubtful that all remaining calorie source were from broccoli and artichokes.

Her patient very earnestly told newFNP that she was uncomfortable with her weight and wanted to change her diet in order to drop some ell-bee's. Nutritional counseling was not so much of a challenge.

But newFNP wondered what happened to the off switch in someone who consumes that amount of soda. It might meet the DSM-V criteria for soda addiction. It is affecting her health, she continues to use soda despite suffering as a result, she has tried to stop but hasn't been able to yet. NewFNP didn't recommend any specific diet, but she did recommend complete cessation of soda consumption in addition to initiation of physical activity.

Can we incorporate infant and childhood nutrition into prenatal classes? Because this kind of whack diet needs to stop way the hell before it starts!

Undecided

Oh my God, does newFNP ever need to get her shit together.

For one, she misses clinic. She loves working at the research clinic because she has awesome colleagues. But she loves working at the community health clinic because she loves the work. (And has a handful of awesome colleagues in the midst of the wackiness.)

For two, how do ladies figure out A) if they want to have kids and B) when the hell to interrupt their very busy lives in order to do so? NewFNP is on the fence and she is also AMA. On the one hand, she sees an iPhone pic of BostonFNP holding her newborn and looking happier than quite literally ever before. On the other, she sees a thirty-something year old woman with an eviscerated perineum after a perineal wound repair dehiscence. NewFNP has a longstanding history of not inviting chaos into her personal life, yet completely acknowledges that kids are kind of a cool chaos. If only newFNP could be a dad...

For three, why in the world did newFNP consent to getting her cholesterol checked the Monday following the Christmas/birthday holiday weekend? How could newFNP, who practically survives on veggies, fruits, Omega-3 supplements and grains, have somewhat elevated triglycerides?? She'll tell you - a weekend full of shrimp dip, bagels and lox, mashed potatoes and birthday cake. NewFNP makes it a practice to completely invert her food pyramid December 24-26 and now look where that practice has landed her. Mother fuck. NewFNP hates not getting 100% on her FLP.

So it looks like newFNP has some shit to figure out this year.

Whatever... bring it.

Happy Holidays 2009

Oh my God, does newFNP ever love the holidays. Know why?

A) Time off.

B) Go shorty, it's newFNP's birthday! Not today, but ’tis the M-F-ing season. For her birthday, newFNP bought herself a cashmere sweater on sale. And an Audi. (Hey, it's diesel and newFNP loves herself some leather seats and dual moonroof.) And she even got a cake and a song at clinic today!

But you know what can put a damper on newFNP's holiday/birthday cheer? A $24,000 medical bill from her grandmother's 24-hour hospitalization. Bear in mind, this does not include one cent of physician services. Those are still to come. Of course, newFNP's sweetheart of a grandma won't have to pay this size XXL bill thanks to Medicare. The Medicare discount is a cool $22,000.

Guess what an EKG ran? $494!! NewFNP did 10 EKGs today and she's pretty sure that her clinic won't be billing any insurance $494 per test performed for the frigging things!

So again, why are we not supporting a public option in healthcare reform? Is there a reason that anyone should receive a $24000+ bill for 24 hours of care? Who in the hell can pay for that?

And if there is someone, is he married?

******

If there was ever a time newFNP wanted a hospital to do its job, it's now. NewFNP is thinking nothing but positive thoughts for Pudge and mature lungs and closed cervices. BostonFNP, keep safe. Love you.

Always have and always will

NewFNP has the raddest grandparents -- all of them.

When her paternal grandfather died while newFNP was in nursing school 3000 miles away, newFNP asked her brother to help take care of their grandmother. BroFNP moved in and cared for her for four years. When her care exceeded what could be done at home, newFNP moved her grandma to her urban jungle. She had been faring rather well for a 94-year old lady with dementia until this week. She had cough, she was tachypneic, and she had unilateral lower extremity edema. (But she always has edema because she's got the ole Norvasc and she's in a wheelchair.)

Now, newFNP and broFNP have power of attorney, DNR, advance directives -- the whole nine. But having all that is all well & good until one needs to use them.

NewFNP's grandma was admitted to the hospital and had a thoracentesis which drained 700cc of fluid from her right lung. Her duplex ultrasound showed extensive DVTs in her left thigh.

NewFNP opted not to treat. Anticoagulation is not the move for a 94-year old woman and won't improve her quality of life at all. Plus, just last week, her grandma told newFNP that she was "ready to hang it up." NewFNP knew that deciding against treatment could mean deciding for a pulmonary embolism. That's just kind of the beauty and the bitch of being in health care -- one understands the implications of one's decisions. And, frankly, a massive PE is not a bad way to go.

Her decision weighed heavily on her as she watched her grandma doze off in the hospital bed. As she waited for the ambulance to transport her back home, she crawled into her grandma's hospital bed and sobbed. Her grandma reached her hand out to hold newFNP's hand.

"Honey," she said, eyes closed,"I hope you're not getting sick. It sounds like you're stuffed up."

"Yeah Grandma," newFNP replied, "I'm a little stuffy." All the memories of summers and swim lessons and shopping for ESPRIT and lunches at I. Magnin and how her grandma consoled her the evening that her mom died were playing in newFNP's mind as she laid next to her.

NewFNP remained in bed with her Gram sniffling and soaking the sleeve of her James Perse t-shirt until the ambulance arrived. Every once in a while as newFNP and her Grandma snuggled, her Grandma would reach her hand up to scratch her head and then slip it back into newFNP's and give her a little squeeze.

"I love you so much, honey," her grandma told newFNP. "Always have and always will."

When she was leaving, newFNP gave her grandma a kiss goodbye. She turned to get her purse when her grandma said, "I want another kiss."

You got it, Gram. Whatever you want.

Pole Position

NewFNP really enjoys IUD placements. She finds procedures fun - a little break from the assessment of DP pulses and the futile attempts to palpate hepatosplenomegaly in her generally overweight patient population.

Today, newFNP had a gregarious patient present for an IUD insertion. NewFNP asked her patient if a colleague who is learning how to place IUDs could observe the procedure.

"Yeah, sure," she replied. "I mean, I used to be a stripper so it's all good."

NewFNP replied, "Oh wow - what was that like for you?"

Some people might be amazed to learn that newFNP had never met a stripper before! She wanted to ask her all the details. How does one learn to pole dance? Do pasties hurt upon removal? What was it like?? Hell, newFNP doesn't even like to walk around the Korean day spa naked, but the rub-n-scrub is worth the lady nakedness. Dollar bills in g-strings would not be worth it to newFNP.

Her patient told newFNP that, not unlike health care, the location of the practice played a significant role in how well one was treated. In ghetto areas, her patient explained, her treatment was not so good. But in nice areas - "with lots of white guys" - it was a pretty good gig.

NewFNP didn't go into it any further, but she would actually really like to learn what it was like for her patient. What was it like the first time she performed? Did she feel hesitation about considering exotic dancing as a job? Was it worth it? Did she feel exploited? Alas, it seemed inappropriate to ask such questions while seated at the business end of the lithotomy position looking past the pierced clitoral hood to the perfectly centered cervical os.

It was the most seamless insertion of newFNP's career. Her patient was completely comfortable and pain-free, talking to newFNP and laughing the entire time.

It's quite nice to have appointments like that during a generally hum drum clinic day.

Two things

One. NewFNP is fucking stoked not to have a mammogram again until age fifty. Not so nuanced a comment, but personal indeed.

Two. NewFNP was leaving Whole Paycheck with bag full of organic goodies and was listening a gentleman on NPR listing the reasons for opposition to health care reform. One reason was the loss of choice. (He didn't specify, but newFNP assumes that he is talking about choice over health care providers as well as the government having a say in what health care can and cannot be provided.) Oh, the irony! After all, isn't there a huge brouhaha over including the choice to have an abortion in the current health care reform debate??!

That kind of stuff makes newFNP want to tell people to suck it.

Choice

NewFNP doesn't need to be convinced of anyone's reasons for seeking abortion - she has been pro-choice for as long as she knew that the issue existed.

But when newFNP met a young woman in clinic this week, she thought to herself, "Now this is a person who should have an abortion." This young woman is 20-years old. She was pregnant for the ninth time and did not care. According to her, she has had seven miscarriages - some of them provoked but she declined to elaborate further. She is bipolar and unmedicated. She is homeless. The father of this baby is incarcerated. She smokes one pack of cigarettes daily. Until a few weeks ago, she regularly used methamphetamine. She was carrying a prescription for Haldol due to her recent suicide attempt.

The one child who she carried to term is in foster care. She opted for foster care rather than adoption because - in her words - adoptive families get too close to the kid. Yeah, newFNP is pretty sure that that is the point of adoption.

So -- chronically homeless and chronically mentally ill. Polysubstance use. In the best of circumstances, a new baby is challenging. This young woman was not experiencing the best of circumstances.

NewFNP hopes that the foster care system in which her six-month old child is placed finds this baby a loving adoptive family who will raise her with love and assuage the effects of the tumultuous pregnancy and the family history of mental illness and drug addiction.

And she hopes that this mom will terminate this pregnancy and will seek birth control services, mental health services, substance abuse treatment and housing. Maybe one day she will be able to care for herself and a pregnancy. But this is not that day.

And it's not newFNP's choice.

Saved yet again

Last week, newFNP had had it. She never wanted to return to clinic again. She had one especially bad encounter with a patient that left both parties feeling upset and involved newFNP telling the patient, "Pregnancy is not a disability - you do not need to quit work yet" in a not-so-nice tone and the patient telling newFNP, "You don't understand -- your job is easy." To which, of course, newFNP had an internal fit of apoplexy. It is a damn good thing that newFNP does not know how to say, "You have got to be fucking kidding me" in Spanish.

That, coupled with a few other institutional issues, prompted newFNP to send her resume out early yesterday morning.

And then, newFNP'll be damned, but wouldn't you know it if a patient reached out and touched newFNP in a way that made her love her job all over again. No - in a way that made her want to stay in her job.

This patient is in her 60's, she is a university retiree from newFNP's public health alma mater, she has Crohn's disease, is a breast cancer survivor, fell and had a major knee surgery two months after her chemo ended and was determined to be unable to care for herself post-operatively in her home as she lived alone. Thus, adult protective services placed her in a hella ghetto senior's community a stone's throw from newFNP's clinic which, in case anyone has been sleeping for the past four years, is in one hell of a shithole area. Prior to this determination, she was living in a peaceful suburb in the foothills of newFNP's city. She hasn't had a mammogram in two years and she is only three years post-mastectomy. She hasn't had GI follow-up in over a year. She feels as though she cannot turn to her children for help.

As she recounted her story to newFNP, newFNP just took a moment to acknowledge the hell this woman had been through and asked her if she wanted to talk to a counselor. She made an expression that spoke of her pain, of her sorrow and of her relief in being offered .

She shook her head slowly, ruminatively. "I could use it," she replied, nodding. "It has been a really hard couple of years."

NewFNP put down her pen after having filled the past medical history form and then some on this woman's encounter form, leaned forward toward her patient and said, "I am going to help you." And she meant it -- she meant it more than she usually does. And she felt the importance of helping this woman more than she has in quite some time.

And she did help her. She got her a mammogram even though mammograms are booked through 2010. She got her a counseling appointment. She overstepped her bounds and gave her a friend's email address in the hopes that this friend had some insider knowledge regarding other communities available. She listened. She cared.

But equally as importantly for newFNP is that this woman helped her. She saved newFNP from utter desperation and frustration with her job.

What a wonderful gift newFNP received today. She is so thankful.

One week follow up

Followers of newFNP may recall that last week she sent a gentleman to the emergency room with a temp of 102.3 and purulent nasal discharge. The day she sent him, he has come to clinic on his bike. When El Conejo was a no-show, newFNP told him that she would get him a cab and that he could lock up his bike at the clinic.

At that time, newFNP had no way of knowing how fortuitous it would be to store his bike for him.

He came today to pick it up, telling newFNP's MA that he was there to pick up his "Mercedes." As newFNP's MA took him to unlock his bike, he told her that the emergency room physicians had drained a lot of pus from his face and told him that if he had waited one more week, he would have lost his eye. He was hospitalized and given IV antibiotics for a week.

He was also diagnosed with leukemia.

Unfortunately, it makes sense. Why would an otherwise healthy 39-year old guy have 6 months of purulent nasal discharge and weight loss? At the time, newFNP was thinking immunocompromise due to HIV. (He had never tested positive, but newFNP was just trying to make sense of the bigger picture.) She had not thought of leukemia when she decided to send him to the ER.

Learning of his diagnosis A) reminded newFNP how crucial it is to consider patients in context and B) made newFNP feel so relieved that she sent him for further evaluation and treatment. Sadly, she knows that in other clinics, he would have received antibiotics and been sent on his way. He's poor, uneducated and uninsured. Maybe he would have gone to the emergency room when his eye was beyond saving. Maybe the infection would have overwhelmed his compromised immune system.

The silver lining is that his purulent nasal drainage is resolved and he has oncology follow-up scheduled. That is one hell of a silver lining.

NHSC ya later!

It's official, bitches!

NewFNP received a certificate and a letter today noting that she has completed her service commitment. Hells yes she did -- a year ago! But newFNP is inclined to disregard the delay and feel thankful that her brand name nursing school was paid for and that her three years in community health indentured servitude offered her an education in and of itself.

In retrospect, worth it. Worth every tear and every ounce of frustration. But she's not running back to sign up for more.

Sunken treasure

There are a few things which, if found in her bathtub, newFNP would wrap in a cloth napkin and tuck away in her lingerie drawer for safe keeping. These include a Harry Winston 3-carat flawless diamond, a bar of gold bouillon and a love letter from George Clooney begging for a second date.

What she would not keep is a year old Mirena IUD that had spontaneously expelled itself from her daughter's uterus.

Granted, newFNP does not have a daughter, let alone a daughter old enough to have an IUD, but she's quite certain that if presented with that scenario, she's not keeping the IUD as some progestin secreting family heirloom.

But this is exactly what happened. NewFNP's patient presented to have a new IUD placed but had no evidence that the IUD string hadn't ascended rather than the whole damn thing falling out. Did she see the IUD or feel the IUD expelling? She did not. Her only proof of expelled IUD was the return of a normal menstrual period after a menses-free year. Sadly, that is not grade A evidence. NewFNP unsuccessfully hunted for strings and then filled out the referral for an ultrasound to confirm expulsion. A uterus is, after all, designed for only one IUD at a time.

Her patient went home and got on the horn to make the ultrasound appointment. Her mom, also a patient of newFNP's, overheard the conversation and, with a sly smile on her face, presented her daughter with a daintily folded cloth napkin. Inside was her Mirena.

Why? Why wait? Why keep the IUD and not let one's daughter know that she is no longer effectively contracepting? Why keep it?

It's all so confounding for newFNP.

And hey -- let's just put that napkin in the trash, shall we? If ever there were a situation that called for cloth napkin wasting, this is it.

You're either in... or you're out!

NewFNP does not love to start her day with a veterinary emergency. Three hundred dollars later, her dog is on the mend and stoned on muscle relaxants. NewFNP needs a more affordable vet.

She furthermore does not enjoy it when she leaves her convalescing dog alone, pushed the power button in her car and finds the tire pressure warning light illuminated when there is no discernible flattening of tires. Those lights just stress newFNP out! To make matters worse, the frigging Prius has a warning light for everything. Too dirty? Warning light. Country music? Warning light. Bad hair day? Warning light.

And then twenty-nine patients later, she can think of some other things she isn't super fond of.

For instance, a 39-year old male with copious purulent and possibly necrotic nasal discharge. It wasn't that newFNP wasn't fond of him. It was that she experienced more of a visceral olfactory aversion. This poor gentleman smelled like a walking abscess. It was challenging to be in the same room with him. This has been occurring for 6 months. NewFNP posits that he has neither a roommate nor a partner. She hopes that he just has a horrible sinus infection or an abscess and not some type of tumor sloughing off. Truly, the smell. She decided to send him to the emergency room which is when he broke her heart a little bit.

She asked him to call someone to take him as she felt she couldn't justify the ambulance ride. He called El Conejo who agreed to pick her patient up at clinic and take him to the ER. NewFNP asked for his friend's name so she could leave it at the front desk and have the reception staff direct him to the back office. Her patient didn't know his friend's real name -- just El Conejo, the rabbit. He never showed. Is it a shock? This man must be so isolated and lonely that he called someone whose real name he does not know to take him to the emergency room. Ouch. NewFNP fed the patient leftover potluck lunch while he was waiting, gave up on the rabbit and eventually put him in a taxi, a sure-fire guarantee that he'll arrive at the emergency room.

Then she examined a patient who told her that she had an allergy -- to hot water. Just hot water. Does she shower in tepid? What if it's cold out?

But what newFNP is fond of is her new cute and affordable (!!) shoe find: Tsubo. In the quest for fashionable and comfy, newFNP has struck pay dirt.

And now she can relax with her dog, eat lucques olives, drink some wine and watch Project Runway. And of these things, she is quite fond.

No. Just no.

Fucking pancreatic cancer.  It is a goddamn awful diagnosis and an exceedingly difficult one to make until it's too late.

Perhaps that is why newFNP's patient received her diagnosis when the tumor was already unresectable and had metastasized to her liver, intestine and lymph nodes.  

NewFNP took one look at her today and knew that something wasn't right.  She had lost way too much weight for that amount of time, and not in a healthy-appearing way.  NewFNP had seen her six weeks ago and noted scleral jaundice.  At that time, she drew STAT labs.  Her acute hepatitis panel was normal, her bilirubin, alk phos, AST and ALT were sky high.  NewFNP's colleague sent her to the emergency room where, during the course of her three-week inpatient stay, she received her terminal diagnosis.

She was born the year after newFNP -- she in in her 30's.  She has four kids under the age of eighteen.  

She has three to six months to live.  If that.  Her oncology appointment is in four weeks -- too long a wait when every week is one of the last she has to spend with her family.

NewFNP is absolutely fucking heartsick about this.  This is a woman who was abused by her former intimate partner, who suffers with symptomatic myasthenia gravis and who has diabetes.  NewFNP cannot believe that after all this woman has gone through, she is going to die.

NewFNP couldn't bring herself to say this to her.  She is, after all, not an oncology NP and she didn't have a quantified prognosis in the very well-organized three-ring binder of information from the hospital.  She told her patient that this is a very serious diagnosis, that the physicians in the hospital had determined that the tumor was inoperable, that there is no cure.  She referred her to the medical-legal partnership to seek out health insurance coverage and, horribly, to draft a will when she is ready.  (As though someone could possibly be ready for this activity given the non-theoretical impetus for doing so.)  She referred her and her children to counseling.  She counted on the personal connections of a colleague to attempt to facilitate a more prompt oncology appointment.  She found a clinical trial that accepts Spanish-speaking patients.

Who is going to take care of her children?  How is she going to have hospice care without insurance?  How will she afford her pain medications?  Who will take care of her children?  NewFNP cannot imagine what would have become of her if her aunt had not raised her after her own mother died when newFNP was fourteen.  It wasn't the right time to bring this up with her patient today.

NewFNP doesn't know what else to do.  She cannot do much of anything.  She hates that.

Reform

Would it surprise anyone if newFNP were to say that she is a supporter of a public option for health care coverage?  Because she is.

NewFNP does not understand the arguments against public health coverage.  NewFNP thinks that Medicare is a pretty cool program -- certainly preferable to elderly people dying in the streets left and right.  And although the reimbursement isn't great and the prescription drug coverage leaves something to be desired, if newFNP's 94-year old grandma needs to go to the emergency room, it's covered.  If she needs to be evaluated for her hypertension, her doctor accepts her insurance -- her public insurance.

Another thing that oftentimes stumps newFNP is this vitriolic opposition to coverage for illegal immigrants.  Um, sorry to be the one to tell you, but this country spends a shitload of money on the medical care of illegal immigrants.  Lest anyone thinks that newFNP's clinic is full of native born Americans down on their luck, think the hell again.  A large proportion of newFNP's adult patients are living here illegally.  Some are applying for green cards and citizenship.  Others are ineligible.  For many, their children were born here.  By and large, the parents were not.

NewFNP is very mindful that she is spending taxpayer money when she is ordering tests, referring to specialists and trying her damnedest to take good care of her patient's complaint within the walls of her clinic.  But newFNP's time is well compensated -- those visits may be free to the patient but they are far from free.

In the absence of comprehensive and - let's be frank - rather harshly defined immigration reform, what exactly is the alternative?  

Not treating someone's active TB because they are illegal residents?  That makes little sense from a public health perspective as that adult living here illegally may spread TB to his child, who will in all likelihood go to a public school classroom where 30 other children may be exposed.  

Or not treating someone's diabetes so that they can present to the emergency room in DKA or blind or with a necrotic Charcot?  That's not going to save anyone any money and it sure as hell isn't going to prevent any suffering.

NewFNP doesn't know the answer.  But she knows that bankruptcy due to medical debt is fucked.  She knows that her patient today, a 40-something year old status post metastatic choriocarcinoma and a citizen, is scared to go to the emergency room for severe abdominal pain because she is already receiving daily phone calls over a $1500 outstanding debt.  

And she sure as hell knows that preventing an illness is far, far superior a plan from an economic, an emotional and a future-oriented perspective than is treating a chronic illness, amputating a leg, tracking down an outbreak of communicable disease or treating anything other than an emergency in an emergency department.  

Is there anyone at all protesting this plan who is uninsured?  Seriously -- anyone?  Have those who oppose a public option - even if it is only for citizens - ever met someone who suffered as a result of lack of insurance?  Are they utterly lacking in empathy?  

Not to be overly dramatic, but is this the America in which we want to live?