Buh-bye.

NewFNP walked out of work today.

Monday was the twentieth anniversary of the death of newFNP's mom.  NewFNP is not old enough to have passed this anniversary, but it came and went nonetheless.  NewFNP was feeling pretty sad about it and had a heartbreaking conversation with her younger brother in which mom's favorite flavor of ice cream was hypothesized about, but remained unidentified.  It seems more significant when the person is gone.

Well, nothing takes the sting out of that miserable piece of crap day than to get an e-mail noting that one will be working every frigging Saturday in February.  NewFNP feels compelled to remind everyone that Saturday clinic now begins at a soul-crushing 7:30 AM.  NewFNP promptly replied to this e-mail assault, employing words such as 'unacceptable' and 'disheartening' and 'go fuck yourself.'  OK, that last one was not verbatim but newFNP likes to think that she conveyed the sentiment in a very genteel fashion.

NewFNP's COO earnestly apologized and promised that he would change her schedule and that she would be working only two Saturdays, as per newFNP's agreement.

At three o'clock today and after seeing 20-something patients, newFNP received an e-mail reflecting the change.  Lo and behold, newFNP had a paltry one Saturday off and, friends, it was not the one she had specifically requested.  She attempted to broach the topic with her COO, but he was late for a meeting.

So newFNP left her patients in her exam rooms, donned her Tom Ford sunglasses and walked out, frustrated and feeling powerless.  

Granted, she only walked around the block, but she could have kept on walkin' if not for the risk of bodily harm via drive by shooting and of credit harm via student loan default.

But instead, she went back, did a couple of exams and then solved the problem.  

The huge drag is that it didn't even need to be a problem.  Dr. Dual-Ivy-League-Degrees offered to work one of newFNP's Saturdays.   The Real Dr. Mc Dreamy is working part time and she offered to pick up another Saturday.  All that really needed to occur was a little communication.

NewFNP is certain that poor communication is a problem in many community health clinics.  But newFNP is sick of it.  She is committed to community health, she is willing to be flexible, she has no intention of leaving.  Is senior management trying to force her out?  

Community health clinics have a hard enough time keeping providers.  NewFNP doesn't need a clothing allowance, but she does need to be treated with courtesy.

She'll probably need a Xanax when the March schedule comes out.

Your shoe problems - solved!

NewFNP is here to help readers in all pursuits to the best of her ability, not just in medicine but in general well-being as well.

As many of us in the health professions know, the perfect footwear can be elusive indeed.  Many of us opt for the Dansko clog, an ever popular and respectable choice.  Orthopedically sound and very European in sensibility.  

NewFNP, however, does not opt for said clogs.  Dansko clogs were all she saw during her years in nursing school.  Danskos and knitting needles.  NewFNP's fellow students were practically wearing down the sturdy Dansko soles while hauling fucking looms to class to make furry, multi-colored scarves.  Anyway, newFNP did try the Dansko clogs but she was always feeling precariously balanced in the ankle department, not to mention that they just didn't go with newFNP's overall aesthetic.

Enter the Sigerson flat.  OK, to be fair, the Sigerson Belle flat -- newFNP is not made of money after all.  The problem with the Sigerson flat is that they are truly frigging flat.  They are so flat that one may as well tape a piece of cardboard to one's soles and fashion a cute printed upper with some wrapping paper from Paper Source.  Cute as hell though they may be, that amount of flat is no good.

So what is a fashion conscious newFNP to do?

Enter the melange of Cole Haan and Nike.  NewFNP would have never thought herself one to tout the benefits of Cole Haan but, oh, that heavenly marriage.  If it weren't for the high price-point, newFNP would buy out the stock of Nike Air-soled G Series ballet flats.  NewFNP, after all, is nothing if not an OG.  And OG's need cute and comfortable ballet flats in pewter leather with satin trim or in red perforated suede with a little sweet white patent leather trim.  

NewFNP is a committed sale-shopper and recommends buying said exquisite ballet flats on sale as comfort doesn't come cheap from ole Cole Haan.

Burn baby, burn.

NewFNP's clinic has had a spike in the incidence of STD's lately. Since Cocoa Brown, two more patients have tested positive for syphilis. Neither of them were Ms. Brown's abused partner. Another patient's downstairs was so disturbing in the olfactory sense that newFNP was quite sure that an animal had crawled up there, homesteaded her vagina and died.

And, finally, newFNP has been burned by chlamydia twice recently. Thankfully, the burn has only occurred in her professional life!

Chlamydia is supposed to be asymptomatic at best and have a mild discharge at worst. It is not supposed to mimic gonorrhea and have purulent discharge and a traumatizing odor. NewFNP fully acknowledges that she is at fault here in that she should have treated the patient for chlamydia when she erroneously treated the gonorrhea. But the discharge, people, the discharge. Who could have thought that little ole chlamydia would cause such a thing?!?

It sucks to have failed public health to re-learn the lesson that you treat for chlamydia when you treat for gonorrhea. But here newFNP is, kicking herself for missing the Chlam.

Let this be a lesson to you, newFNP readers. Be liberal with your STD antibiotics.

Judiciously liberal, of course.

TV junkie

NewFNP has enjoyed her weekend. Hairdo. Facial. NYT Crossword. Juno. (Better late than never.) And, today, newFNP has indulged in a guilty pleasure: TV.

NewFNP generally does not have cable, but has something called "antenna service" through her local rip-off cable company. Otherwise, she could not watch any TV at all, not even The Office or How I Met Your Mother and that is just not realistic. But every once in a while, her rip-off cable company graces her with basic cable. She never knows how long it will last, but she has enjoyed fully four hours of a frustratingly glorious program: What Not To Wear.

NewFNP would kill to get on a program that gave her five grand to go on a shopping spree in SoHo. Plus free hair-do and a little make up advice? Please. And these ladies get all pissy about having the opportunity to throw away their Kohl's and softer side of Sears wardrobes! Puh-leez!! Say goodbye to the puffy paint sweatshirt and Christmas cardigan and hello to Olive & Bettes and Bloomies on Broadway.

NewFNP would be such a better NP if she had five thousand dollars worth of free clothes. She would even promise to read peer-reviewed journals on the subway rides between boutiques!

Dare to dream, newFNP. Dare to dream.

Dream is just what newFNP will do on her day off tomorrow. Dream a little dream of fashion.

Shiver me timbers!

NewFNP was a huge fan of the Pirates of the Caribbean movie. Not the one where the guy played the organ with his face tentacles and Johnny Depp was swallowed by a giant vagina, but the first in the trilogy in which a swashbuckling Johnny Depp was swarthy and sexy with his pirate eyeliner and his pirate shirt and his pirate vernacular. NewFNP, however, did not adopt the pirate fashion and make it her own.

Apparently, however, the new nutritionist at newFNP's clinic was so moved by pirate couture that she has incorporated it into her daily wardrobe.

When newFNP starts a new job, she wears some sensible yet flattering trousers and a cashmere sweater with some low heels or flats her first day. She's not all pearls and Lilly Pulitzer, but she tries to put together something smart.

What she does not wear is a wide teal stretchy headband with a high, loose, devil-may-care ponytail, a black sweater, teal herringbone trouser shorts and black lace-up knee high high-heeled boots. That is exactly what the new nutritionist was sporting during her meet and greet. She must have left her parrot and eye patch in the car.

NewFNP wonders how she will do her nutrition education. Will she be all: Arrrr! Me bonny lass - eat ye veggies or ye shall walk the plank. Will she advocate for Pirate's Booty over Hot Cheetos and, if so, is she part of some pirate mafia that gets a kick-back?

NewFNP is actually quite thankful to have the pirate nutritionist on board. Since the recent departure of our gaudily-dressed dentist, newFNP's clinic has been woefully lacking in fashion mishaps such as the camel toe and work no-no's such as the low-cut blouse/Wonderbra combo.

Looks like things are picking up! Arrrr!

T.G.I.F.

NewFNP loves her Fridays off. A little hiking, a little Bloomingdales sale to spend birthday 2006's gift certificate, a little Cosby Show rerun*. OK, that part is not so great but newFNP is one of the few remaining people who do not have cable so she is willing to indulge in a little retro-TV for a half hour.

She has spent a fair amount of her free time today, however, wondering what happened with a kid she sent to the ED on Wednesday.

NewFNP is generally so overwhelmed with type 2 diabetics that she had almost forgotten that type 1 diabetes existed as well. She even expects to diagnose her pediatric patients with type 2, given the degree to which she encounters the consumption of Hot Cheetos, Gatorade, and whole milk in her patients, as well as the prevalence with which she notes acanthosis nigricans, abdominal striae and hidden penises on physical exam.

However, newFNP would be remiss if she forgot that those wacky type 2 patients account for only 90% of diabetes diagnoses. She is fairly sure that she caught a kid in the early stages of Type 1 this week.

What a lousy 10% to be a part of!

This normal weight twelve year old boy -- whose well-child visit and urine dip were unremarkable a mere six months earlier -- came to our clinic with the chief complaint of abdominal pain. NewFNP's list of differentials includes things like appendicitis, AGE, UTI, nephrolithiasis and post-Winter Break school avoidance. As a general screening tool, newFNP has impressed upon her MA the importance of obtaining a urine dip on all of her tummy ache complaints and her MA never fails her in regards to this task.

Well, imagine newFNP's surprise when this kid's urine was chock-a-block full of glucose and ketones! When newFNP checked his fingerstick glucose, it was 313 and this was not a kid who had fed at the fast food trough prior to his visit. He had lost 3 pounds since his last well-child visit. He didn't look bad, just a little tired. He didn't smell ketotic and his breathing was normal.

NewFNP hasn't seen type 1 diabetes since she was working as an RN in her training hospital. She hasn't diagnosed it before and she was not sure if this kid's abdominal pain had anything to do with his diagnosis. Well, as it turns out, acute abdominal pain is a common presenting symptom of type 1 diabetes. Huh!

NewFNP's clinic has nothing - no RN's, no health educators, no nothing. Therefore, some quick education with the kid and parent about newFNP diagnostic suspicions and off to the ED. NewFNP is hopeful that the patient will bring back such important paperwork as c-peptide test results, discharge instructions and the name of his endocrinologist.

And if he comes back in tomorrow, newFNP will be waiting there for him at seven-fucking-thirty. She will make every effort to be pleasant, but it does, frankly, seem a stretch.

* In this episode, Rudy gets sent home by the school nurse when she gets her first period and Claire wants to have something called "Woman's Day" with her. Apparantly, Lisa Bonet and the other daughter - Vanessa, if memory serves - both had Woman's Days and Vanessa's involved a trip to the Plaza Hotel for brunch. NewFNP went to the Plaza to celebrate her her 30th birthday, not her frigging menarche, a day which she still curses! Those crazy Huxtables!

Community Health Ink

Long before newFNP was newFNP, she worked at a little county health department in the city where she completed her undergraduate studies. One patron of the health department was a fellow who had his face tattooed. He didn't have anything specific, just a lot of black ink obscuring his face. The effect screamed both "mental illness" and "don't talk to me - I am dangerous." Perhaps this was like a warning to would-be interlopers. It worked on newFNP; she never talked to the dude.

NewFNP has seen her fair share of hideous tattoos at her clinic. Bad butterflies, homages to dead loved ones, gang affiliations and plenty of crosses and dots in the web of the hand between the index finger and thumb which newFNP presumes to indicate gang membership or a history of incarceration.

However, there are some tattoos that just burn an indelible image in one's mind. Could anyone forget the image of the masturbating lady proudly displayed on the leg of one of newFNP's young patients? His mother must have been so proud. Imagine newFNP's surprise when a second patient had a strikingly similar tattoo! She had no idea there was such a market for these forays into the repulsive and permanent.

Well, Dr. Dual-Ivy-League-Degrees had a patient today who may have held the gold medal in repulsive tattoos. Apparently, this chap had a lady - naked, of course - tattooed on his abdomen, legs spread widely and intersecting at his umbilicus thereby allowing his belly button to form her anus. Classy and thoughtful! It must take a real talent to envision the design and then make it come to fruition without giving the lady one leg shorter than the other or some other such defect. Good thing the guy didn't have an outie! That would just be gross.

NewFNP presumes that these guys are straight as she knows no gay men who objectify women in this way. But what newFNP can't quite wrap her mind around is who exactly are the women who have sex with these guys? How low can one's self esteem get?

It is rare that newFNP sees women with such patently offensive tattoos, but she does recall one woman with a tattooed necklace that reads "Fuck niggaz and money" in two-inch script. More sad than offensive, really - at least in newFNP's eyes. NewFNP wonders who has screwed over this woman so incredibly that she thought to permanently emblazon her chest with this statement. Any newFNP doesn't quite understand the 'money' part. Apparently, this woman does not have six-figure student loan debt to repay.

And a final question: who does these tattoos? Perhaps they could do us all a favor and be trash collectors or dog catchers or captains of industry, huh?

If the shoe fits

If newFNP didn't have photographic documentation of herself salsa dancing and Corona-drinking in a far-far-away city a mere five evenings ago, she would swear that she had been trapped in her urban community health clinic Gulag for ages.

NewFNP wants to storm into the packed waiting room and scream: People! Let's band together and stop this nonsense! You have a cold? Go home! You have diabetes and ate a doughnut, a tamale and a double mocha frappuccino before your appointment? You're fired!

And those would be the easy cases. Today, newFNP's cases were not so.

Influenza? Check.

Child sexual abuse? Check.

Crying overweight ladies (plural) who don't want to have sex with their husbands? Check. (Prayer - please, please, please do not let newFNP ever fall into this group!!)

Parent who cannot name her child's apparently chronic, perhaps genetic, illness? Check.

NewFNP is not a parent, but if she were, she is pretty sure that if her child had some inborn error of metabolism or some genetic defect, she would at the very least have the wherewithal to write down the name of the fucking thing on a sticky pad. This would hold true even if newFNP were not an FNP. If newFNP were a fancy nail salon girl or a go-go dancer or even a rodeo clown, she would know enough to learn the name of the condition. Even more so if she herself had undergone genetic testing and had some genetic-something or other, as her patient's mom had.

When one spends nine years in post-secondary education, one's bar for normal intelligence is so absurdly skewed. Friends, newFNP is living 'regression to the mean' and this lady was at least two standard deviations below! NewFNP thought that everyone was like herself and her super-education friends.

Wrong. Oh sweet Lord, how wrong she was.

NewFNP hates to just chalk it up to 'stupid,' but sometimes the shoe fits. Can newFNP write "Mom not so bright" in the progress note? It only seems fair to give the next provider fair warning.

A fine how do you do

Outside of clinic, newFNP's life is going swimmingly. She's got some cute new sneakers and slimming workout pants, her romantic life is picking up and she bought a ceramic flat iron which effortlessly turns newFNP's curly mop from wild to sleek.

Clinically speaking, not so much. It's not that the patients are any more challenging or frustrating. No, it's that, starting this Saturday, newFNP's clinic is open from 7-fucking-o'clock until 3:30. Formerly, Saturdays were a merciful 8-to-2. This vicious change was announced in an e-mail this week. No opportunity for discussion, no mention of increased salary due to extended working hours. Just an 'Oh, by the way...'

Seven o'clock, people? Seven? Come on! NewFNP isn't even a wild party girl, spending all night in the club shaking her ass to reggaeton while downing Red Bull and vodka! All she wants is to enjoy a few glasses of Pinot Noir on Friday night, maybe watch a movie or paint her toenails and then peacefully sleep until 6:30 and still make it to work on time.

NewFNP is none too pleased.

When in grad school, newFNP frequently saw students, whom she presumed to be undergrads, walking around campus in their PJs. Not even cute Juicy sweatpant-PJs, but Spongebob flannel pieces of crap. Can newFNP wear velour Juicy sweatpants to work on Saturdays? They're a hundred bucks, for Christ's sake. It seems a shame to only wear them at home.

2008

It's always tough to return to work after Hanukkah, Christmas, newFNP's birthday and New Year's Eve. It's even tougher for newFNP when her plane lands thirty minutes late and she returns to her apartment at 12:30 AM and is so enthralled with her book that she just cannot put it down and then all of the sudden, it's 1:30 AM and newFNP utters "fuck" and switches off the light.

Seemingly, five minutes pass and newFNP awakens to the sweet sounds of NPR and again utters "fuck" and starts her day. Her day which ended 33 patients later.

Fuck 2008 so far. Thankfully, bad weather is in store so there will perhaps be a lull in the patient flow.

NewFNP is in the home stretch. Her service commitment ends this year and she will be a free agent. NewFNP, however, is a glutton for punishment and is eagerly awaiting the application for another two years of indentured servitude in order to pay off more loans. If only community health paid like professional sports, newFNP would not still be living in a one bedroom apartment and cursing her six-figure student loan debt.

Damned fancy schools with their Latin-inscribed degrees!

School debt and overworked days aside, newFNP is looking forward to yet another year of sharing stories. Truly, how could newFNP ever leave her ridiculous practice? Do stories like these exist in private practice??

The saga continues

Cocoa Brown is fucking crazy.

When newFNP returned to work and asked Dr. Dual-Ivy-League-Degrees if Cocoa had returned to clinic for her syphilis treatment, she stated that she had and proceeded to recount a story that put Cocoa Brown into a special kind of crazy league. NewFNP is not talking about the kind of crazy that causes you to feel that it's appropriate for your BFF to check out your herpetic labia or the kind of crazy that remarks con gusto about vaginal odors. No, this is a new kind of crazy.

One might call this kind of crazy "felonious."

Apparently, when CB learned of her multiple STI diagnosis, she confronted her new partner, a wise and responsible move all in all. That is where wisdom and responsibility end and crazy as fuck enters. CB's partner, upon learning of her HSV infection, informed her that herpes was not likely to be the only infection that she had and that she had better check in with her doctor.

At this point, Cocoa Brown understandably lost her shit. Who wouldn't? One would assume that words such as "motherfucking asshole shitlicker" and "son of a bitch piece of shit no good dog-humper" would be employed, that voices would assume a fever pitch, that the sensation of imminent explosion resulting from extreme anger would be palpable.

One would not expect, however, that Cocoa Brown would attack her disrespectful partner with a 2x4 that had exposed nails with such vigor that he was hospitalized, but that is in fact just what happened. According to newFNP's colleague, she seemed not at all disturbed by this.

CB went on to explain to Dr. Dual-Ivy-League-Degrees that she had previously been incarcerated for prostitution and "other things." What could those be, newFNP wonders? Aggravated assault? Assault with a deadly weapon? Jaywalking? Furthermore, Cocoa is apparently treated for mental illness.

Just a hunch, here, but newFNP thinks that she might need a med adjustment.

Cuckoo for Cocoa Brown

NewFNP's readers are already familiar with our good friend Downtown Cocoa Brown. As it turns out, she not only had a culture confirmed herpes infection, but also had a bonus STD: syphilis!

Hooray!

NewFNP, upon receiving the result from her lab and seeing the reactive FTA with a 1:8 titer, called her local public health department. She asked the helpful STD man if he had any record of having ever treated Ms. Cocoa Brown for said treponemal infection. He had not. NewFNP then proceeded to call Cocoa and ask if she had ever been diagnosed or treated for syphilis. She had not. NewFNP strongly encouraged her to return to the clinic A.S.A.P. in order to glean a better syphilis-related history and to start her some some sweet Pen G. Oh, and in the meantime, do public health a favor and keep those sweet legs tightly closed, would ya hon?

This was Tuesday. She swore she would be in Wednesday at 8:30 AM. NewFNP even requested an overbook. Therefore, one can imagine the importance newFNP placed on this visit. Around 9:30 on Wednesday, newFNP received a phone call from Cocoa's friend, the vagina voyeur, noting that they were a little on the late side in coming in for the syphilis appointment but that, not to worry, they would be there.

The dynamic duo never showed.

Again, newFNP feels compelled to point out the differences between her experience as a patient and that of her patients'. If newFNP has a blemish, she is powerless to not treat it. And she is talking about a micro-papule that she and only she can appreciate while her otherwise dewy and glowing skin is illuminated in the magnifying mirror. Intralesional kenalog STAT! If newFNP's vag* doctor told her that she had motherfucking syphilis, she would be destroying herself with penicillin!

NewFNP received a call today from the friend. The reason that Cocoa Brown had not returned to the clinic is that her friend's foot hurt "real bad." Ever heard of a bus? Taxi? Tricycle? Walking?

They swear that they will be there tomorrow. NewFNP, alas, will not. Her new work buddy, Dr. Dual-Ivy-League-Degrees, will. As sad as the case may be, newFNP knows that Dr. Dual-Ivy-League-Degrees will have quite a time with these two.

* rhymes with badge

First base.

NewFNP found herself in something of a clinical pickle today. She has a patient for whom she has been caring for his diabetes for quite some time now. However, he had not been to clinic in over a year when newFNP happened to run into him last week as he was exiting his dental appointment.

"How are you?" he asked, in Spanish of course, as he gave newFNP a warm hug - a practice of several of newFNP's patients. "How was India? Are you married?"

"India was great," newFNP replied. "And I'm single."

He proceeded to tell newFNP how he was in the midst of a divorce and that he would take all of newFNP's worries away by making her his second wife. Nice gesture, but newFNP will decline with a wave of the hand and a shake of the head.

Fast forward two weeks and here this gentleman is in newFNP's exam room for diabetes care. He told newFNP that he and his wife were considering divorcing because he, at age 45, wants a child and she, at age 50, is unable to provide him with one. NewFNP noted to herself his mid-life crisis, practiced supportive listening and attempted to steer him back toward the safer ground of DM2.

He, however, was not to be swayed. We chatted a little more about decisions, how one never knows what life will hand them, blah blah blah. What is this, talk therapy? After some more chatting and a sprinkle of dietary education thrown in for good measure, newFNP stood up from her rolly stool and declared that it was time to go to the lab.

At this point her patient stood up, went to embrace her and kissed her. On the lips. No tongue, but still. He then invited newFNP to "have babies with him." He was joking, of course. Right? NewFNP blushed eight shades of red and told him to knock it off.

What a bummer. NewFNP used to look forward to her visits with this intelligent and, today notwithstanding, thoughtful patient. Now she needs to wear a teeth guard and perhaps some Mormon underwear before she enters the room.

Damn.

Balls - redux.

When purchasing her new car earlier this year, newFNP felt confident that it would not be tampered with when she parked it in her clinic's ghetto-esque area. Why, you ask? It is because, time and time again, newFNP noted that all around her were big trucks with flashy 16-inch rims, SUVs with the same, minivans with those spine chilling stick-figure family stickers, or piece of shit junkers with piece of shit spinning rims. NewFNP bought a hybrid, a very hybridy-looking hybrid. They are not so common or coveted in newFNP's hood.

NewFNP loves cars. In her dream world, she would have her sweet hybrid and she would have a sweet Audi S6 all-wheel drive wagon for snowboarding with George Clooney. But she would not, under any circumstances, buy a big truck, fashion a skull whose eyes glowed red when she stepped on the brakes to the trailer hitch and hang from its truck underbelly a huge pair of swinging rubber bull testes.

Yet newFNP has seen this accessory more than she would have liked to. For the record, she would have liked to have seen it exactly once, just for shits and giggles, but to have seen it repeatedly feels somewhat abusive. Does newFNP really need to be hypnotized by faux balls as she leaves work?

Who hangs these balls from their truck? Do they have female partners who deign to be seen in such a masculinely adorned vehicle? Do they feel appropriately shamed when they go to the bull-ball store and weigh the decision regarding color? Do they cup their purchase in their palms and feel pride? And - really - who chooses blue?

NewFNP knows the message that these chaps are trying to put out there. They are saying, "Do not fuck with me. Smoke comes from my nostrils when I am incensed. Furthermore, my testicles are laden with semen and my semen, if you must know and - trust me - you must, is the stuff of legend. In fact, I am quite certain that there exists a tome entitled 'La Leyenda de mi Semen.' My erections are formidable."

The message received by newFNP is more like this: I am compensating for my small, poorly functioning penis, I do not know where the clitoris is, and I drink too much.

Can't we just go back to sexy mud flap ladies?

Downtown Cocoa Brown

NewFNP has rarely, if ever, found herself in the position of requiring - let alone desiring - a friend's presence while at the doctor. Truth be told, she would rather keep that part of her life private. Especially as it relates to her lady business. Good news? Great! Bad news? Private!

However, if newFNP's patients want to drag their sisters/friends/cousins to their appointments, who is newFNP to deny them? Of course, newFNP asks family members to exit the room during sensitive histories or exams, but respects it if her patients want to use the buddy system.

This morning, when newFNP read the chief complaint of "boil on her vagina," she felt a little glee at the thought of incising and draining what she assumed to be an abscess. It's been a long time since newFNP performed any mini-surgery and, frankly, she's been missing it.

Alas, it was not to be.

NewFNP received permission to make this a group visit and proceeded to ask her patient who, by the way, had a BMI of 41, how she could be of help. Her friend, whose BMI was easily 50-plus, piped up with, "She got a boil on her cocoa brown!"

NewFNP elicited the pertinent history and got the patient into the lithotomy position - no easy task - and began to survey the region when her friend came around to get a lay of the land as well. NewFNP quickly maneuvered the makeshift drape in order to cover her patient.

"Whoa, whoa, whoa," newFNP said. "Is it okay with you if she looks?" NewFNP's patient, astoundingly, gave her the go ahead and her friend jumped on in.

Again, newFNP would prefer that all of her friends would just stay the hell out of her own cocoa brown. Permission to view the pelvic exam denied!

This lady's cocoa brown wasn't exactly rocking the cocoa puff, per se, but more of the cocoa herpes. When newFNP asked her if she had a new partner, she answered in the affirmative. After determining that this was a male partner, she asked if he was a good guy. Her friend emphatically answered that he was, in fact, not. To which, newFNP's patient informed the room that she would no longer be "fucking with him."

Good then. NewFNP provided some safer sex counseling, offered further STI screening, and bid these two fine ladies adieu.

Go Bruits!

NewFNP knows a thing or two.

For instance, she knows that she should not wear black trousers with brown shoes, even if the shoes are Sigerson Morrison and cute as hell. She knows that grown men should not wear bikini underpants. In fact, if she were pressed, newFNP would assert that no men - regardless of age - should wear bikini underpants. Not even George Clooney. Because if there is anything that could render an otherwise ridiculously handsome and obviously virile man pathetically unattractive, it's bikini underpants.

NewFNP also knows that when one auscultates a carotid artery, it should not sound like there is a frigging Harley Davidson Chopper racing through at breakneck speed. And it sure as shit should not be happening on both sides. No, the finding of bilateral rumbling carotid bruits is undesirable. In concert with a fasting glucose of 392 and a BP of 204/90, it makes newFNP's eyes glaze over and forces her to consider a career as a nail salon girl. In an upscale salon, of course.

If newFNP were to adopt a "half-full" approach, she would be gratified to observe how well one can look and for how long one can push on while one's blood supply to the head is compromised.

What's that, you say? You're dizzy? No shit.

The reason that newFNP's is able to observe just how long a person can survive with said pathophysiology is that this patient, like so many others, is uninsured. Sure, when she went to the ED after passing out in her chair for no apparent reason and newFNP called the attending physician to give a little carotid bruit heads up, one would think that this patient would have exited the hospital with, oh, let's say having had a duplex ultrasonography and an MRA. One would be wrong.

NewFNP sent off the referrals today. Frankly, until this lady gets health insurance, newFNP is not hopeful that her condition, which clearly warrants an urgent evaluation, will be so.

Did newFNP mention that this patient is 57 years old? Not exactly a spry fifty-seven.

Yeah, you're in the right place.

NewFNP recently had a conversation with a good pal from grad school, BostonCNM (not to be confused with although currently and temporarily co-habitating with BostonFNP). BostonCNM has recently changed practice sites from a cushy suburban practice with an educated clientele committed to a midwife assisted birth to a ridiculously busy community health center in a wrong-side-of-the-tracks area of Boston.

There is something deeply validating about sharing the experience of working in a completely fucking disorganized setting, yet loving the work that you do -- and bitching about it with one of your BFFs.

It started newFNP thinking about how one might truly know that they are working in urban community health. What are the requisite community health bona fides? NewFNP will share them with you.

1) In general, your patients will not speak your primary language. Their language might have no written form or may consist of clicks, thus making them impenetrable to an otherwise educated and teachable person. You may perhaps speak the language, but that would mean that you or your parents had acumen which started you off on the Spanish language path at an early age. NewFNP's mom had that insight. Sadly, newFNP was both intransigent and snobby and insisted, at the age of eleven, that she would speak French. While this proved quite helpful during her Tahitian vacation at the age of seventeen, it has proven itself much less so in the years since.

2) You will run out of crucial supplies. These may include but are by absolutely no means limited to: specula; lead testing strips; table paper; otic thermometer probe covers; patient drapes/gowns; charts; and medications. Furthermore, you will discover that these supplies are missing at inopportune moments, such as when your patient is in the lithotomy position, covered with paper towels and with two serving spoons fashioned into a speculum by the ingenious placement of folded cardboard and a rubber band in lieu of the real deal.

3) You will care for patients who have absolutely no idea how to care for their health. You will feel astounded at this. This feeling will not go away.

4) Your patient no-show rate will be in the 50-70th percentile. Therefore, your front desk staff will bring in tons of walk-ins. And then, one day, your no-show rate will be 10% but they will still let in the walk-ins. On those days, you will be fucked.

5) You will work with people who frustrate you and who could, at times when one is feeling less than generous, be considered incompetent. NewFNP has noted this before, but believes that because it is so intrinsically linked to community health practice, it is worth noting anew. See Office Staff Rant for a more thorough investigation of this phenomenon.

6) You and your co-workers will have more than one job. Medical assistants double as referral coordinators. Admin assistants place the orders. Providers do everything. NewFNP makes copies, fills out a trillion forms, writes letters and fields phone calls from senior management asking about this or that. This does not lead to efficiency, nor does it lead to satisfactorily completed tasks. Moreover, it may contribute to job dissatisfaction.

7) You will have crazy stories to share with your pals who work in law or fashion or business. You will frequently hear phrases such as "No fucking way" or "What the fuck?!" or "Jesus, how long do you have to stay there?" when you recount these stories.

8) In the end, goddammit, the goods will outweigh the bads and you will feel good about your work at the end of the day. But not so much in the morning when you see the line snaked around the block as you walk into another day of 10-15 minute appointments.

Balls.

Seriously, what the fuck happens to people over a holiday weekend? NewFNP is gone for four days and the whole world goes to pot.

NewFNP is continuing her week of meaningful encounters, which is lovely and, given newFNP's semi-cynicism, oddly life-affirming. NewFNP is not one to curl up and hug one's inner child, but it has been making her feel good to do good. Because, you know, she is so used to doing evil.

But newFNP just wouldn't be newFNP if she didn't talk about a jacked up penis, so let's get on it. Figuratively speaking, of course.

There is something to be said for having the parent in the room for at least part of an encounter with an adolescent male. For instance, when newFNP asks something along the lines of, "How can I help you today?" and the kid responds, "Oh, you know, I had a headache a few months ago," newFNP is appreciative when the mom jumps in with something like, "And you were hemorrhaging from your penis and went to the ED."

OK then. Let's get down to business.

When newFNP sees a 16-year old guy with a hickey the size of Wyoming on his neck and hears about penis hemorrhages requiring trips to the ED and stitches, she has two differentials: aggressive masturbation or buck-wild teenage sex.

In order to screen for other risky behavior, newFNP asked, "Were you having sex when this happened?"

"Noooo!," he responded, a look of horror and shock on his face. "It was in the morning!"

Ah, to be a teenager and not yet have experienced the beauty of the morning sex. NewFNP had to grin.

Apparently, he just had to pee really badly and then all of the sudden, his foreskin just blew up like a fucking landmine and his penis started bleeding like he was beating off with Freddy Kreuger's scary blade-hand. Yeah, buddy. Whatever you say. NewFNP will just send that urine off for GC/CT just to be on the safe side. She feels somewhat assured that this young patient will not be having sex anytime soon -- at least until the fucking penis stitches dissolve.

In memory of J.L. 1927-2007

NewFNP hasn't had a patient die since she was in training.

Today she received news of her first patient death. She got a phone call from the funeral home, letting her know that her 80-year old patient with cor pulmonale had died over the Thanksgiving weekend and would she sign the death certificate? Alas, as an NP, she cannot but her MD co-worker would.

He died at home in his sleep on Saturday. On Friday evening, he told his son that he thought he should come on in to the clinic the next morning. His son found him the next morning, "cold" in his bed. This same son came to clinic today just to stop by and thank you to newFNP for the care she had provided. It was incredibly touching.

NewFNP often felt as though she hadn't done much to help this old gentleman. Sure, she wrote his O2 and furosemide prescriptions and closely followed him and his lower extremity edema. But what newFNP remembers most about her appointments with this guy and his son, totalling maybe five over the past year or so, was that she smiled when she walked in the room because he was easy to smile at, that she answered his questions when he had them, that she sent him to the ED at the right time early on in his care at newFNP's clinic. He joked with newFNP with the ease that only elderly men have with far younger women: playful yet appropriate, full of vibrancy and mischief.

NewFNP doesn't spend a lot of time reflecting on her role in her patients' personal histories, but she very much is. The manner in which she cared for this patient exemplifies how she wants to practice with all of her patients. While it is perhaps an unattainable goal in her current place of employment - given systems failures that are far beyond her control and her own variable capacity to control her frustrations - she would like for all of her patients to leave their encounters feeling cared for.

After all, there are many ways in which to care for one's heart.

Feelin' good, feelin' *real* good

NewFNP's four-day wonder-weekend is winding down. Thus, newFNP forced herself to return to her normal Sunday routine of gym and a trip to the farmer's market.

While at the gym this morning, newFNP was perusing the current issue of The Journal of Family Practice and stumbled upon an article which sought to elucidate the role between marijuana use and the use of Viagra (sildenafil). Although the sample size was only 231 and was only selected from one outpatient practice in Brooklyn, fully 59% of the Viagra poppers did not have diagnosed ED. They were, in fact, recreational users of the little blue pill. Of this sample, 76% of them admitted to feeling a kinship to Snoop Dogg, not in relation to weapons charges or hos, but to loving themselves some weed. These stoners also noted that they sometimes procured their Viagra from "friends" or "street vendors." NewFNP is so worldly in some ways, yet so naive in others. She was just not aware that a market existed for this type of prescription drug.

Maybe A&E will do an "Intervention" about it. NewFNP imagines that the actual intervention would contain the plea, "Your ridiculously hard penis is ruining our relationshop! We never go out, we never invite friends over - we just sit around and smoke weed and have sex because of your crazy penis! I can't take it anymore and I will no longer enable you with my multiple orgasms!"

It is a stretch for newFNP to remember the days when marijuana played any role in her life, but it would have been when she was in high school and, frankly, newFNP is quite certain that - weed or no weed - teenagers are going to have sex. After they eat some Hostess and Taco Bell. Therefore, newFNP thinks that the population polled for this study is older, say in their 30's-50's, although age was not reported on.

NewFNP found the article amusing and appreciated that someone had to think of the research question in the first place. It really begs the question of the researcher, "What was that guy smoking?" Additionally, the article brought up the following questions for newFNP.

1) Who are these middle-aged guys who smoke weed? Do they still live in their parents' basement watching Soul Plane and playing air guitar, or are they just normal guys with girlfriends or boyfriends or wives and with careers and college educations? NewFNP hypothesizes the latter, but is willing to allow that the former do exist as well.

2) Where do these people buy their weed? NewFNP isn't all D.A.R.E. and Nancy Reagan, but she would be scared as shit to get busted. NewFNP will just stick to red wine. Unless you know anybody. Kidding - geez, calm down.

3) Are these guys popping Viagra because their libidos are diminished from the mary jane? Or are their libidos diminished by the paranoia that their special friends are in the DEA? Or because their ladies are all red-eyed and messed-up-haired with powdered sugar from the 6 Hostess Donette Gems she just consumed all over her t-shirt ? Or do these guys just want to experience more pleasure? Here is newFNP's null hypothesis: weed smoking = love of feeling good. Sex feels good. Maybe it just feels better when you're stoned and hopped up on Viagra.

4) Why do we still care if people smoke marijuana and why is it illegal? Just like the OGs say - regulate, motherfuckers, regulate. Don't drive stoned, don't get stoned while you're hanging out with your kids in the jumpy house at the neighbor kid's birthday party because, even though you'll really want to, you can't go in. Just think of the tax revenue we could create of we added a tax to your pack of joints? The schools would benefit! The food industry would certainly benefit. While we as a country, astoundingly, cannot seem to get behind gay marriage and tighter emissions standards, maybe we could all join hands, pass the duchey on the left hand side, and demand that we don't criminalize our weed smokin' fools!