First Job Survival Kit

NewFNP has had more than one request for advice as to what in the hell to take to your first job.  NewFNP figures that, given the season, at least a few other people may have the same questions.  So here we go.

  

The Basics:

Obviously, stethoscope and DTR hammers and your brain fall into the 'crucial' category.  

White coat - maybe.  Depends on the practice.  NewFNP has forgone hers entirely although sometimes misses its plentiful pockets in which she would jam all manners of clinical provisions, thus leading to a very unflattering hip-spread look.

A PDA or, at the very least, a calculator are helpful all day long when faced with '80-90 mg/kg/day in divided doses' calculations.

Your physical assessment book.  NewFNP still refers to hers, especially for the not often used tests and for neuro assessment.

Two phone numbers: the person you can reasonably ask your most shameful question - something that you absolutely should have learned in school but were too busy playing Brickbreaker on your BlackBerry and you missed it, and someone who you know is intelligent and experienced and will help you with your tough cases.

Snacks.  Both carbohydrates and proteins.

Diet soda/coffee/tea. Caffeinated.  Water.  NewFNP still rocks the Nalgene as it was a gift from a VIP in her life, but the stainless steel are now considered the de rigueur water bottle.

The Oh Yeah - Good Ideas:

A derm book - Habif is the best but Fitzpatrick is acceptable, less spendy and has a wealth of information in a paperback form.

A ruler for measuring positive TB tests and derm lesions.

Good pens.  Yes, your clinic will provide you with pens if they are not yet equipped with EMR.  But these pens will suck and hurt your sensitive fingers.  NewFNP has the ugliest writer's bump and she has had it for years because she holds her pens hard.  But now she has comfort-grippy pens and her writer's bump isn't quite so Quasimodo-esque.

Pregnancy and BMI wheels.  Yes, they are on your PDA but frankly, it's quicker to just use the old wheel system.

The Sanford Guide, not to be confused with the Sanford & Son guide, which is probably a lot funnier.  NewFNP has an appreciation for The Guide which she must admit to having lacked while in school.  She's considers herself a convert.

The After Clinic must haves:

NewFNP knows that not everyone drinks and she doesn't want to be an advocate for alcoholic beverage consumption, but in her experience, a nice glass or two of a delicious red goes a long way in the Calgon-take-me-away type of relaxation.  She likes L'Automne and Roessler La Brisa and Fratelli Perata, but there are tons out there!  Find a good one and buy a case.  And a rabbit-style opener.  Why struggle?!?

Exercise.  For stress reduction and to work off those donuts/cookies/cinnamon rolls that are ironically always around health clinics.

Support.  Your first job is hard.  You need to have friends and partners and family to take care of you when you are taking care of your patients.

Your personal swears.  Everyone has them.  Not all of them are as colorful or as plentiful as are newFNP's but they're all good and effective!  You'll need them.

And the most important thing to take to your new job:

A sense of humor.  Without it, you are three ways to Sunday, up a creek without a paddle, take no prisoners, no joke fucked.  

PSDA - thumbs *down*

Just when newFNP was reconsidering her decision to go into clinical practice, she was privileged/mandated to attend a conference for a quality care collaborative in which her clinic participates.  There are only three providers who are currently working within this collaborative; the first two attended day 1 of the session whereas newFNP held day the fort on day 2.

It was about as pleasant as being waterboarded.  

NewFNP does not want to create PDSA cycles ever, ever again.  She does not want a valid plan to be that an MA is going to put a specific form in a specific place.  That is not a plan for which one should need to devote time, energy or a written plan for action documented on duplicate forms.  She certainly does not want to evaluate that plan in clinic.  

One of newFNP's plan involved three data collection points.  She was chastised for that being too much.  Three?  Too much?  In the course of a ten-month condition which is handily broken up into trimesters?  It seems like we're all selling ourselves short if that is too much.

NewFNP was so happy to see her diabetics and prenatals and well-child visits today.  It's nice to be reminded that one's job could be to do PDSAs or be a in a cubicle analyzing god-knows-what or working in the home appliance department at KMart or something like that.  

NewFNP will take the challenges and rewards of clinical practice any day, although she wouldn't mind a little time for computer Tetris every now and then!

Massive

NewFNP's patients are coming in sicker. Totally anecdotal, of course, but what on newFNP isn't? She doesn't have anyone who has scratched a hole in her skull and exposed her brain, as Atul Gawande writes about in this week's New Yorker, but she has just had people come in that, truthfully, should be seen by internal medicine or psychiatry or, in this case, oncology, surgery and radiology.

This young, single mother of three first noticed the small bump on her upper arm, beneath the surface of the skin, about a year ago. The demands of single parenthood and her low-paying/no-insurance-providing job had kept her out of medical care. When asked to describe the size of the initially noticed lesion, she drew a circle 4mm in diameter.  When newFNP measured the mass in clinic, it was 12.5 cm by 15 cm.

It was firm.  Not firm firm, but softly firm and disturbingly firm.  Soft tissue sarcoma firm.  Oh shit firm.

NewFNP saw and felt the mass and instantly flashed back to her recent patient with two huge malignant masses.  She wrote the urgent referrals to her county system, but she knows that this young woman will need to go through the emergency department in order to get the CT and biopsy that she needs.

NewFNP is sick of this.  She is deeply frustrated by having nowhere to turn for her patients who need more care than newFNP's clinic provides.  She is frustrated that her major metropolitan area's community clinic association has so few resources for the community clinics.   And she is frustrated that she is so busy on a day to day basis that she cannot create her own backroads system of referrals.

Our patients wait.  They wait until their symptoms are unbearable.  They wait until they borrow someone's glucose monitor and see "HI" and then they wait some more before they come in, wondering if their 30-pound weight loss and dry mouth and frequent trips to the john could be caused by diabetes.  They wait until their likely rhabdomyosarcoma is visible from across the room.

In writing this, newFNP realizes that this is only half true.  There are the other group of patients who present for every URI, hangnail, bruise and stomach ache that they experience.  NewFNP sort of wishes that these worried well would come in less and the very needy new diabetics and cancer patients and HIV/AIDS patients would come in sooner -- when newFNP and her colleagues could actually help them.

Small world (after all)

As you may recall, newFNP was feeling fed the fuck up with her clinic.  This prompted her to send her CV to her local major university/research center/medical center.  This was on Saturday at 5PM.  She was expecting that they would call, but that they would call in a month. 

They called Monday afternoon.  And not just HR -- the medical director of the position for which newFNP applied.  She was seeing patients and was too astonished to answer the phone.

She was recounting her tales of woe and her desperation and job-seeking and rapid return phone calling to her pal and Scrabulous nemesis during the walk to the Death Cab concert Monday night.  "Hmmm," he said, "That sounds like the project that CHO works on."  Confirmed.  An MPH colleague, to whom newFNP was a mentor during MPH orientation, has worked there for years.  

Last night, newFNP was dining with her other public health gal-pals in honor of a great public health pal visiting from her South African international health job and was detailing yet again her frustration with work and her possible venture into academic medicine.  

"Come to South Africa!" newFNP's friend stated.  Interesting, but pass.  Amongst other things, if newFNP ever wants to get married, it seems as though a move to South Africa might decrease those odds.

As she described the research area, another friend stated, "My brother is doing that same kind of research."  

"What's his name?" newFNP asked.  Medical Director.  NewFNP had spent a half an hour locked in an exam room, talking to him on the phone just hours before.   

Has newFNP recently mentioned that she lives in a really major, major metropolitan area?  This project has a staff of ten.  Ten.  NewFNP isn't mystical or religious or a believer in fate, but these coincidences are somewhat testing her beliefs (or lack thereof).  

And she met with the medical director today.  He didn't promise newFNP anything, but he did say the magical words, "Well, you are very well qualified."  

Word.  NewFNP has mad qualifications.

If you can't take the heat...

NewFNP is hot.  She is - sadly - not 'hot' in the new hair-do, flattering trousers, sassy flats sense of the word.  No, she is talking about the Holy shit! Who turned up the heat and why in the hell don't I have central AC kind of hot.

And newFNP is also frustrated.  This is not a good combination.

NewFNP is sending out a cry for help.  NewFNP does not like herself much of the time anymore when she is at work.  She is mean.  She hears the harsh tone of her voice and cringes.  She is endlessly frustrated by the half-assed work of the support staff.  Each and every day, she is correcting other people's mistakes and dealing with other staff members' shitty attitudes and disappointed by the lack of improvements in the system despite her efforts.  She hears that people have called her bossy, which is true, and a bitch, which has been true but is not something newFNP is in her outside clinic life.  NewFNP wants to not care about what people think, but she does.  And newFNP does not want to be a bitch.

NewFNP spends so much time looking for unfiled labs, asking her MA to find unfiled labs and doing laps around the poorly designed clinic in an attempt to find her MA in order to ask her to find unfiled labs that she could probably see an extra 1-2 patients per day if this one issue were to be solved.  She is fed up with the growing piles and piles of unfiled charts on the floor of the file room while the clinic staff sits and chats about whatever crap it is that they talk about.  She is frustrated that the very young and very overwhelmed clinic manager is impotent when it comes to actually managing the clinic and the staff.

As an aside, there are many reasons that drive the resistance against change in newFNP's clinic.  When newFNP eventually leaves, she'll share them with you and it will make your heads roll.  But the infrastructure is so unique that it would be a dead give-away if anyone in the know was to stumble upon the blog.

So what to do, what to do?  NewFNP doesn't want to leave, but she doesn't want to be a bitch and she doesn't want to be frustrated.  

Her CV looks pretty slick.  Will her local major university -- and her alma mater -- think so too?  Because newFNP submitted it in an act of sheer desperation.  She is looking for options.  And a pension.  And a salary increase.  But to leave would mean giving up what brings newFNP joy - caring for her patients.  

A conundrum indeed.

Thankfully, newFNP has the Death Cab concert, her super-duper friend from South Africa visiting and not one but two grad school pals visiting this week.  She'll be too busy with her real life to worry about her work life.

Atypical.... and typical

On the day of the first power outage at newFNP's clinic, there was a teenage boy waiting to be seen who had - the day before - fallen down a flight of stairs, broken his nose, split open his lip and fad a face that resembled Chunk from 'The Goonies'.  He had been seen in the ER and just needed a referral to get his face fixed.

NewFNP talked to him and his parents outside, grabbed a flashlight with the brightness of a penlight, went inside the cave-light clinic and finished the kid's referral.  This was month's ago, was no big deal and, frankly, newFNP had forgotten all about it.  

Apparently, the CEO had not.

During the clinic's staff meeting, he acknowledged newFNP's contributions in front of the entire staff.  NewFNP can imagine how he told the story of her relatively minor contribution to patient care and then called out her name several times, only to have someone say the inevitable: She's still seeing patients.

NewFNP's one moment to shine and she missed it!

Oxy

In case anyone missed the memo, community health is challenging.  It's not only that patients are ill and uninsured and have more medical and emotional needs that the clinic and any given provider can reasonably handle.  

It's also that the patients just don't 'get' the system.  

For instance, newFNP had a charming but terminally ill seventy-five year old woman walk into clinic today.  The woman has cancer.  How does newFNP know this?  Well, it helps to have pathology reports noting lung cancer and metastatic adenocarcinoma.  However, even without the reports, newFNP wouldn't have missed this one.  

She wasn't on oxygen, she didn't have a tracheostomy.  So how could newFNP have known that she had cancer?  Did she call Miss Cleo's psychic hotline?  Does she have x-ray vision?

Nope, it's because the woman had two huge visible tumors.  One was on her anterior chest wall, about the size of a baseball and just as hard.  The other was on her abdominal wall.  It was rock hard as well... and draining.  And it was large.  Really large.  Hugely crazy large.  Bigger than Posh Spice's fake boobs.  NewFNP is talking 8-by-6 inches large.

Now, this woman has known since January that she has inoperable cancer.  And where might her oncologist be?  In a state some twenty-five hundred miles away from newFNP's clinic.  She stated that she got bored and just wanted to get away.  NewFNP appreciates that, if one is dying, they should do whatever the hell they please.  Travel the country, visit the ghetto!  

But just one thing - get your oxycodone refilled before you leave.  

As newFNP has previously noted, the walk-in scheduled med refill is not one of her favorite visits.  But when you have very obvious cancer, newFNP doesn't even think twice about writing that oxy prescription.  Knowing what lay ahead for this woman, newFNP accompanied the prescription with a referral to the palliative care team at our local public hospital.  

Skills Lab

This is what passes for a rich Monday evening in newFNP's life - the new Death Cab for Cutie album on heavy rotation, an 80-cent pig's foot from the El Salvadorean market and some borrowed instruments/pilfered sutures from clinic.  

Good times.  

 

Hold on

Clinic is a roller coaster.

In one room, you have a scrawny four-year old in full Spiderman regalia flexing his little biceps telling you to look at his muscles while awaiting you in another room is a social worker from children's services telling you that she needs to remove two children who are currently in the clinic from their father's custody and she wants your help.

NewFNP chooses the first room. She'll take a pass on the second. Alas, the second room chose her as well.

NewFNP has sympathy for people who have addiction problems. But it is hard to have sympathy for parents who cannot get it together to find help for sobriety while they are pregnant. When your newborn screens positive for cocaine, that is - frankly - bad. It's just bad. There is just nothing good about the fetus-cocaine combination. NewFNP received a phone call from the hospital letting her know that she would be seeing this baby for her newborn exam and that the children - the newborn and her 18-month old sister who shares a name with a slang term for marijuana - were in the custody of their father under the supervision of the department of children's services.

She was unprepared for the social worker to appear in clinic, to tell her that the dad's tox screen was positive for marijuana, and to tell her that she would be taking the children into protective custody after newFNP did her newborn exam. And, oh, by the way, would newFNP help her?

This is where newFNP is a huge spineless jellyfish. She has this frigging affliction of wanting to make life easier for others, all too frequently sacrificing her needs in the process. What she should have said is, "No way. NewFNP will do the exam, but you call the police and you do not put newFNP in the position of betraying her patient." But the social worker had already stated that she didn't want to call the police and escalate the situation, a point of view to which newFNP is not entirely unsympathetic.

So newFNP did the exam and - it pains newFNP to say - lied to the father and told him that she needed to re-weigh the six-pound baby to ensure accuracy. She exited the room, baby in hand, and deposited the newborn in the hands of social worker #2. She returned to the room, laden with guilt, with the social worker and the clinic manager. The social worker explained to the father why the children were entering temporary protective custody. As the shock wore off and the reality set it, this young man - covered in gang tattoos - wept. He cried. He hit the wall. He lifted his shirt to dry his eyes, revealing even more gang tattoos.

NewFNP knew that she was betraying the implicit trust of the provider-patient relationship the entire time she was participating in this shady operation and she felt appropriately guilty about it. But when she saw all of the tattoos, she, for the first time at work, actually felt scared. She has seen National Geographic Lockdown and she knows that one doesn't get initiated into a gang by knocking mailboxes over or kneeling behind your buddy while another friend pushes him and makes him fall. No, gang initiation generally involves a more illegal activity. Like killing. And the time when one's children are taken into protective custody is generally not the time when one is thinking clearly. NewFNP isn't given to paranoia, but she did feel like she had foolishly placed herself and her clinic in potential danger. She called the social worker the following day to talk with her about this, but she just got a voice mail.

NewFNP went for a beautiful bike ride in a nature preserve after work yesterday. It's all single trails and fire lanes and deserted bunkers and really, really, really long hills. Fun going down, not so much going up. She got to the top of the hill and stopped. She looked out over the ridiculously beautiful view below her and attempted to prevent her heart from exploding and the lactic acid from melting her quadriceps and thought, "I am so lucky. I love my life."

NewFNP is sure that she is overreacting and that this guy will do nothing to further jeopardize his custody of his children, who he quite clearly adores. But she will listen to her gut if she is ever in that shitty position again. The answer will be no. Sorry, but no. No, newFNP will not aide and abet. She will wait to do the exam until the police arrive, but she will not take a child off the exam table and away from her father ever, ever, ever again.

The obstetrical history

When newFNP considers the perfect amount of children to have, she generally comes up with one number: two.  However, if newFNP does not get on the stick - so to speak - she will have exactly zero.

NewFNP's patients do not seem to share her values when it comes to parity.  Granted, newFNP has nothing but unfettered access to birth control and is also nursing a semi-paralyzing fear of parenthood.  Be that as it may, she finds the obstetrical history of her elderly patients who grew up in developing countries fascinating.

Today, she asked an 80-something year old lady how many pregnancies she had had.  Fifteen.  Fifteen.  How many births?  Fifteen.  Her vagina must hate her.  As is common with multigravid women in developing countries, some of her children did not survive infanthood.  Seven of her children died during the first year of life.  

It is not uncommon that newFNP's patients are grand-multips.  NewFNP has heard so many 10's and 12's and 14's when she asks about number of pregnancies, she is hardly surprised by the answers anymore.  But these women generally have some type of birth attendant with them.  Sister, mother, nurse, lay midwife, doctor... someone is generally there to assist in the birth.

One seventy-odd year old lady, however, gave birth alone.  Twice.  NewFNP was sure that she had misheard.  Alone?, she asked.  Alone.  No midwife?  No, no midwife.  Twice? Si, si, the patient assured newFNP with an amused smile on her face.

NewFNP's patient went on to tell her that she just had the scissors on hand, birthed the baby, tied off and cut the umbilical cord.  NewFNP's face must have betrayed her amazement.  Her patient explained that there was a woman in her community that gave her something to drink beforehand -- to give her strength.  What in the hell was in that drink and can newFNP get some of it before she goes to work on Saturdays at 7:30?

It's quite a contrast between prenatal care at the fancy hospitals here in the U.S. with ultrasounds at every visit and 3-D ultrasounds and CVS and amnio and EAFPs and episiotomies and forceps and fetal scalp monitoring and NSTs and epidurals and IV morphine and 25% or higher c-section rates.  NewFNP isn't saying that she isn't down for a little picture of the fetus action, but it is nice to remember that pregnancy and birth aren't diseases and that women's bodies are, in fact, designed to support the entire process.  

NewFNP's fantasy letter of resignation

Forgive the lapse into first person.

*******************

Dear Medical Director and Other Pertinent Senior Managers,

It is with absolute joy that I, newFNP, submit to you my letter of resignation.  Hooray!  To quote a decreasingly relevant but still important songstress, "Holiday-ay [oh yeah, oh yeah], celebray-ate [come on, let's celebrate]!"

I see that you are scratching your heads wondering why I, newFNP, may be leaving.  Is it the unreasonable workload, you may be asking?  It is not.  Is it the lack of support staff in the clinic? Not that either.  Is it the incessant drama?  Alas, I have grown immune to it.  Is it the working through lunch almost every day?  No, in fact, I, newFNP, think of that as part of my calorie restriction plan!  

Is it the fact that, despite our mutual agreement that adults with chronic diseases should have thirty minutes allotted for physicals, they continue to have fifteen minutes and I, newFNP, am expected to take good care of them in that time frame?  Ditto for new prenatals and IUD insertions.  No, I have begrudgingly accepted that I must see another patient faster in order to have a longer time with the more demanding patients.  I, newFNP, am a natural-born problem solver!  

Is it the fact that I, newFNP, earn $15,000 less per annum than the provider who referred the patient with the markedly enlarged prostate to nephrology?  I know, I know, I am not supposed to know the salaries of other providers but - guess what?  I do, and that still is not the reason I, newFNP, am leaving.  Is it the fact that, despite having brought concerns to you all several times, only to have you nod empathically and promise to address these aforementioned concerns, you do nothing?  Amazingly, no.  

As you can see, I, newFNP, am willing to put up with a shitload of crapola because I am a schmuck and committed to community health!  So you can go ahead and pile this dump-truck of crap on me and I, newFNP will stay!  I do not expect that you will thank me, only that I will receive my bi-weekly paycheck.  I must admit that you have unfailingly delivered in this!  I wonder if you laugh when you see how many hours I, newFNP, have worked for the amount of money you pay me?  Not that it matters.  As I have already noted, I am not leaving over paltry concerns such as salary.

No, I am leaving because you continue to fuck up my schedule.  That's right.  After almost three years of employment, you continue to change my day off and have appeared to have settled on Tuesday.  Well guess what?  No thank you, Sirs and Madams.  I understand that so-and-so has school and so-and-so has another job and so-and-so never works Saturdays.  Because I, newFNP, have demonstrated flexibility in the past, I see that you saw fit to take advantage of that yet again.  Why should I ever have doubted you?  You are a consistent bunch, after all!  Consistent in screwing up my schedule!

No hard feelings, eh?  

Taking this job and shoving it, fondly of course.

-newFNP

*******************

NewFNP is clear that she cannot say this to her supervisors, but she is unsure why they are so unfailingly unrealistic.  Is it wrong to hate them?  NewFNP thinks not.  Is it, after all, the natural order of things.

Tuesdays off?  Didn't we already go through this with the last inept scheduler?  

NewFNP is nothing but a hater tonight.  Not even a delicious homemade meal of sesame-encrusted seared ahi with organic broccoli and rosemary fingerling potatoes could extinguish her fiery distaste of her clinic and its retarded scheduling.  

He has AIDS

Truth be told, newFNP generally loves to be right.  It's not her best personality trait, but it is what it is.  She's working on it and nursing school certainly helps one learn how to say, "I was wrong."   

This is one case in which newFNP wishes she were wrong.  She had almost convinced herself that her patient was just seroconverting and that was why he had this malaise, this acute drop in immunocompetence.  As if all of her worry and her wishes and her day-off appointment coordination and letter writing could change the course of the pathophysiology at work throughout this young man's body.

But newFNP got her CD4 count today.  It showed his absolute CD4 count as less than 20.  His percentage of CD4s was three.  The low end of normal is 20%.  NewFNP's heart broke.

This patient has really touched newFNP.  It is probably for his loneliness, his isolation.  NewFNP has always been drawn to these people and has always wanted to show them that there is someone in this world who cares for them.  This is perhaps a result nature (newFNP is what she is) and nurture (losing her mom at a young age and all its subsequent emotional detritus).   Whatever the psychoanalytical insights, newFNP is willing to go the extra mile for these people.

It is probably also because this patient knows that newFNP is there for him and newFNP knows that he knows that he can count on her.  Today he told newFNP that she was the only one to visit him in the hospital and that he never feels shame when he sees newFNP.  NewFNP knows that he is keeping his diagnosis from the majority of people in his social circle so it felt good to hear that he felt cared for by newFNP and her staff.  He gave newFNP and her MA heartfelt thanks and a warm hug as he was preparing to exit the exam room.

Which was where the hug-fest ended and the pissed off newFNP began.  Her lab MA refused to draw his blood.  If he would have refused in front of the patient, newFNP would have stroked out.  Thankfully he had the good sense or good luck to refuse while the patient was still in the room.  He knew that the patient was HIV-positive because newFNP didn't want the patient exposed to all of the ill people in the clinic until he is on PCP prophylaxis and ART.  Therefore, newFNP's MA asked him to either clear the lab or draw the blood in the room.  

NewFNP is in a quandary.  She supposes that an MA may refuse to do a task.  But can the lab MA refuse to draw blood?  We have and use universal precautions for a reason.  We treat all patients with dignity and we treat all of their blood as potential pathogen-carrying fluid.  So how does newFNP approach this?  Education, newFNP supposes.  But she is just so pissed!  Is de-stigmatizing HIV only an activity for educated people?  God, newFNP hopes not.  We need some ACT UP in the lab!

Furthermore, why was this man discharged from the hospital without PCP prophylaxis and an appointment with an HIV specialist?  NewFNP is awaiting the hospital records, but is pretty frigging disappointed that he left only with a repeat prescription for his original fungal infection. Is it possible that the hospital staff chose to ignore his HIV status and not at all assess his immunocompetence?  Is that the care newFNP can expect when she sends her patients there?

More and more, newFNP is missing real public health.  She is missing the sense that her work is saving people, is preventing illness.  NewFNP is generally not to full of self-inflation, but she didn't go into healthcare to diagnose HIV when it is actually AIDS, to diagnose diabetes when it has already impacted eyes and kidneys and feet.  

It is so sad, so utterly disinflating.

NewFNP left work an hour after the clinic closed tonight.  She relished the only quiet time of her day as she made the abnormal lab list, she wrote a couple of e-mails that she hadn't been able to get to earlier in the day and she updated this patient's confidential HIV report, noting his AIDS-defining CD4 count.

She feels like shit tonight.  Calorie restriction be damned!  Ice cream, anyone?

Three-peat

Would anyone believe newFNP if she were to tell you that the power went out yet again at clinic today?  True story.  Although to look at the patient population and to hear the language spoken, one might think that they had taken a wrong turn and ended up in - say - Mexico or Guatemala with their associated electricity issues.  One would, however, be mistaken.  

Several of the flashlights from the outage less than two weeks ago went AWOL, the generator arrived yet filled the halls with the unmistakable scent of gasoline, sending the dental director into an asthma attack and yet, newFNP and her colleagues, including the podiatrist, continued to see patients.  

Want that toenail removed?  Bring your own flashlight!

Period

NewFNP remembers her menarche all too well.  She was preparing to go to swim team practice while spending the summer with her grandparents.  Her coach, Aaron, was hot and newFNP was pretty heavily working a schoolgirl crush.  NewFNP's mom had had "the talk" with her some years before so newFNP knew what was happening and she was none too pleased.  

First period?  Swim practice?  Hot coach?  Bad.  

NewFNP's grandma, after congratulating newFNP on her passage to womanhood, called newFNP's mom to tell her of the news.  NewFNP's mom seemed happy and proud, clearing indicating to newFNP that all adult women were insane not to recognize menarche for what it felt like at the time: a disaster.  The only thing that could have made that experience worse for newFNP would have been if she would have been at her dad's house.

Which is exactly where newFNP's young patient was when disaster struck.

This ten-year old girl spends a lot of time with her dad and he brings her to each and every of her clinic appointments.  NewFNP knows them pretty well and thinks that this man is one of the best fathers newFNP has ever met.  Generally, he is really clear about his concerns or needs when he brings his daughter to the clinic.  So when he came in and told newFNP, in Spanish, that his daughter was here to see newFNP because she 'was developing', newFNP didn't quite catch his meaning.  When he told her that his daughter was now 'a miss', newFNP was equally stumped.   Bilingual newFNP?  Yes.  Bicultural?  No.  It took his daughter saying "I got my period" for newFNP to get on board.  

Dad asked newFNP to do some explaining and exited the room.  NewFNP let her patient lead the conversation.  There were some basic questions.  Will it hurt?  Should you carry supplies with you?  Will it come every month? Why do girls have their periods?  

Now, newFNP has never really given 'the talk' before and her recollection of her mom's talk elicits only memories of embarrassment and desires to return to her room and listen to some Duran Duran albums.  

So newFNP just talked about it medically.  She told her young patient that girls have periods so that they could have babies when they are older.  Her patient wondered how blood and having babies went together.  NewFNP talked about a nutrient-rich environment for babies to grow.  She drew a picture of ovaries, a uterus, a cervix and a vagina.  Clearly, newFNP will have to work on her talk and her art if she ever has daughters.  

The young girl looked at the drawing and took in all that had been discussed.  She took a pensive pause and asked newFNP, "Does the baby come out of the same hole as the period?"  NewFNP responded that it did.  Again, her patient paused although it was clear to newFNP that her mind did not.  "But that hole is small," she said, "and babies are big."

Amen, sister.  Amen.  

She went on to ask, "Why does having a baby have to hurt so much?"  No shit.  NewFNP has asked herself that several times.  And then she immediately downs her birth control pill.

We talked about bodies being made of muscles; about how even though we have periods, we don't need to have babies until we're older; about breasts and sports and school and growing up.  

She left, questions answered, ready to go back to being a ten-year old girl.  Dad shot newFNP a look of thanks and of pride yet clearly tinged with a bit of sadness because his little girl is growing up.  It was quite sweet.  

Home sweet home

NewFNP has just returned from a glorious long weekend with her graduate school pals. She ate good food, hung out with her friend's kids - one of whom called her Frank Gehry fish necklace a 'banana phone', drank too much wine and shopped in a very hipster area of an across-the-county metropolitan area.  It was a great weekend and newFNP misses her dear friends already, but it sure feels lovely to cross the threshold into one's own apartment.

Before newFNP departed, she checked in at the hospital where she had transferred her HIV+ patient.  He was admitted for presumptive PCP and was still spiking temperatures.  He was set to receive a blood transfusion for a hemoglobin of 7.2.  He was in isolation due to concern for TB.  

This is the guy that the paramedics gave newFNP a hard time about?  One of the paramedics actually asked newFNP, "Well, did you listen to him?" when she told him of her PCP suspicion. No, dickhead, newFNP makes it a practice to not examine her patients prior to calling for EMS. The vast majority of the paramedics are so great and sort of participate in the group effort we all undergo to attempt to keep our patients well/alive, but this interaction brings to mind another frustrating experience with EMS.  Last time, the asthmatic kid was admitted for several days.  This time, her patient is still in the hospital.  She talked to his nurse this morning.  IV Vancomycin Q8 hours and still spiking temps.

NewFNP wishes that she wasn't right about this one.  But she also doesn't want to have a fight in the hallway with the stubborn paramedic.  NewFNP - believe it or not - is trained to make decisions such as when to send patients to the hospital and she doesn't want to duke it out in the hallway.  And, with this guy, she got the distinct feeling that he just wanted to blow off the transport and make a point of questioning newFNP's judgement.  Is it possible that he didn't want to transport someone with HIV and a fulminant facial rash with a suspicion of AIDS?  NewFNP hopes that is not the case.  She would much rather have him think that newFNP is a big fat idiot.  

NewFNP wishes that she knew more about HIV management.  Of course, newFNP would not be able to provide such services in her clinic without social work and drug assistance and support for remaining clean & sober.  Nonetheless, newFNP feels like her HIV management knowledge hits an abrupt wall soon after diagnosis.  Perhaps a good CME topic.

Seriously... again?

NewFNP really wanted to do primary care.  She wanted to be out in the trenches, preventing diabetes and HIV and obesity and the like.

What a fucking sucker newFNP was.

In newFNP's clinic, there is a paucity of true primary care.  There are many reasons for this, not the least of which is that newFNP's patients come in the the clinic already sick.  NewFNP spends as much time putting out fires (read: lowering>500 blood glucose) than she does educating diabetics about the pitfalls of the all-carb breakfast.

But newFNP's clinic is also lacking in early intervention.  It's like the frigging uncontrolled disease rodeo and the providers need to lasso those buckaroos back into control.  It sucks.

Today's case in point.  Last week, a 31-year old man came in to see newFNP with what newFNP determined to be a diffuse cutaneous tinea infection - essentially covering his face - and a 23-pound unintentional weight loss over the previous five months.  Although he denied HIV risk behaviors, newFNP tested him.  

When his result came back positive, newFNP attempted to reach him by phone to get him back into the clinic.  It has been an ongoing struggle for our front desk staff to remember to ask for updated contact info and this was one patient whose new phone number slipped through the cracks.  NewFNP felt horrible in learning this.  How in the world would she contact him and get him into treatment?  How could she have let public health down and not updated his information herself?

Fuck that, newFNP decided.  She grabbed her clinic manager and walked the five blocks to his house today.  Pretty much every staff member that heard of her outreach plan looked at her as though she had utterly lost her mind.  One asked if she was bringing a gun with her.  She did not.  She knew that the address may not have been correct, but she needed to fill out the HIV case report and thought it best if it was completed to the best of her abilities.

Now, newFNP works in a metropolitan center that is rather renowned for its urban blight.  She is generally so busy that she doesn't leave the confines of the clinic during her work day.  But today she ventured out and really saw what all the fuss is about.  Sure, drive by shootings and gang warfare get all the press.  But what the fuss is about is a lot of loafing and mid-day drinking.  Perhaps, on a larger scale, one might say that this fuss is about unemployment and bleak future prospects, but newFNP has been so damned heavy lately - she just can't go into all that.  She, thankfully, was spared the gang-related drive-by shootings.

As she walked those five blocks, newFNP was struck by how an eleven mile drive really transports newFNP into a whole different world.  When newFNP hits up the liquor (OK, wine) store, she rarely - if ever - sees groups of people hanging out or talking on pay phones, all the while with their toddlers in strollers drinking extra large juices or their school-aged children decidedly not in school.  When she has a weekday off and walks to the store, it's rare that she sees groups of middle aged guys just lounging on the front lawn, shooting the shit and drinking Budweiser tall boys.

But that is exactly what she saw as she walked up the street, clinic manager in tow, and cautiously approached the address listed on his chart.  NewFNP's clinic manager inquired as to the patient's whereabouts, to which one man replied, "You mean the guy from Honduras?"  Hmmm... that is not information with which newFNP was armed.  Another guy said, "Oh, you mean the one with the spots on his face?"  Bingo.

According to the Budweiser posse, he did not in fact live at the house, but across the street. One gentleman offered that newFNP's patient was cooking in the back and went off to retrieve him. The men told newFNP that there was a point during which her patient could hardly get out of bed and they wondered what was wrong with him.

It's safe to say that her patient was surprised to see her.  She asked him to come with her the clinic and he agreed to be there a couple of hours later.  When he arrived, this 31-year old man's temperature was 103.1.  His lungs were junky - wheezing and rales.  His O2 sat was 96%.  

Not only did this guy learn of his HIV+ status today, he was transferred by ambulance to the hospital to rule out pneumocystis carinii pneumonia, an AIDS defining diagnosis.  

It was a heartbreaking appointment.  He lives alone.  His entire family is in Honduras.  He has no phone.  He has been clean and sober for a mere six weeks.  He told newFNP that it would have been better had he never known, that he would be better off dying.  

NewFNP told him about the advances in care and medications, about the many services available to HIV-positive people in this huge city, about how he has the resources, albeit limited, of newFNP's clinic to support him.  But newFNP knows that this is a socially isolated, marginally literate, extremely poor man whose social circles may be more likely to shun him than to support him.  Honestly, newFNP is as concerned with his emotional well-being as she is with his physical.

And, for the second time, newFNP gave an HIV+ test result not when the patient was generally well and had natural defenses intact, but when the patient was ill.  When they likely had AIDS at the time of their diagnosis.

That is not right.  It's not right.

Mother's Day 2008

NewFNP is at home, listening to Neil Diamond in honor of her mom, Nancy, who died twenty fucking years ago at the age of thirty-eight.  She had a cerebral aneurysm.  But that is the least interesting thing about her.

She trained as a journalist but worked in public affairs after her divorce.  She instructed newFNP to call her every day after she returned home from school, which newFNP did without fail.  She was hilarious.  She watched Magnum PI regularly and remarked more than once that Thomas Magnum had cute buns.  From newFNP's standpoint, she seemed to make people around her - her friends and colleagues and family - happy.  

She loved Asian design and had issues of Architectural Digest lying around the house.  She had a license plate frame on her black Nissan sports car that said, "Nancy - 90% Angel" which brought newFNP absolutely nothing but mortification.  She had thick calves which newFNP had the misfortune to inherit.  But she also had sparkling blue eyes and newFNP got those too.  She wore Obsession or Chanel No5.  She used Clinique and blue eyeshadow.  She was never without polished nails.  She doodled when she talked on the phone.

She was a single mom since newFNP was six and her younger brother two.  She allowed her house to be overrun by pubescent girls once a year for newFNP's birthday sleepovers, which always involved a lot of pizza and horror movies and tee-peeing some poor soul's house.  When newFNP had to stay up all night in order to be sleep-deprived before having an EEG after having had a lone seizure, she stayed up playing Bargain Hunter and other games that must have been mind-numbing to her. In Monopoly, she was always the thimble.  When newFNP was almost fourteen, she came into newFNP's room as newFNP was watching the Iran-Contra hearings -no joke - to let newFNP know that if she ever needed to go on the Pill, she should come to her.  Yeah, thanks Mom, now good-bye.

She smoked Kents and had a butt-ugly yellow robe that she wore every day that newFNP then hated but would kill to have now.  She bought expensive shoes on sale and had clothes in her closet, the hall closet and newFNP's brother's closet.  She wore fancy lingerie because she said it made her feel good.  She framed a painting that newFNP did when she was two and a half and hung it in the dining room, saying that she could have paid thousands for it in a modern art gallery.  It now hangs in newFNP's bedroom.

The day that her aneurysm ruptured, newFNP was waiting for her on the front porch, knowing that she was going to be late for her piano lesson and would get in trouble not only for not having practiced enough, but for her tardiness as well.  NewFNP was mad at her for the latter. It still pains newFNP to think of this.

She had been going to doctors for over a year with headaches before the aneurysm ruptured. She was stoic, however, and never appeared to be in pain, although there were days when she came home from work and had to go straight to bed because of it.  Perhaps her doctors never could have thought....?  NewFNP is keenly aware of this whenever she sees a patient with headache.  

Although absolutely off topic, newFNP wishes that she could share more of her mom with you, but she had only fourteen years with her.  

It wasn't enough.

The return of Cocoa Brown

Just when newFNP was thinking that she was running out of stories to share, the elusive Ms. Cocoa Brown returned to the clinic!

NewFNP walked into clinic this morning with a spring in her step and noticed Cocoa's best friend sitting in the waiting room. She was not hard to miss, what with the 250-something pounds and the bright yellow sweater and shorts ensemble. It wasn't until she had almost entered the back office did she hear Ms. Cocoa Brown call her name.

"Hi newFNP!" she cheerily sing-songed. Now, newFNP has been trying to get in touch with her for months in order to follow up on that pesky syphilis. It's always, "Tomorrow - I'll be there tomorrow." Thus, newFNP gave Cocoa a look that said both "finally" and "where have you been?"

"Don't be mad," Cocoa told newFNP, "I've been in jail."

NewFNP can hardly think of a better excuse by which to deflect one's accountability for n0t making it to one's clinic appointments than that of incarceration. Apparently, the felony warrants and copious tickets were too heavy a burden for Cocoa and she turned herself in.

And now here she was, by her accounts sober except for the occasional Bartles & James wine cooler, which - in her estimation- have no alcohol.

While newFNP was addressing the need to re-check an RPR to monitor titres, she had her MA move Cocoa's hypertensive pal into another room to perform a screening EKG. A different MA tried unsuccessfully to draw Cocoa Brown's blood. NewFNP twice tried unsuccessfully to get blood from her tiny veins. A third MA took a break from setting up the EKG to give it a whirl, also to no avail.

Cocoa Brown graciously offered to return to the clinic for her venipuncture another day, but newFNP was having nothing of it. Yes, it is a torture, but frankly, obtaining that blood sample was a high priority. NewFNP sent her to hydrate and she opted to do so in the room where her buddy was having her EKG.

Fine.

It was at this point that the power went out.

NewFNP's MA, Cocoa Brown and her half-naked 250-pound friend were all in the exam room, Cocoa Brown with her two glasses of water, her friend with her paper gown and EKG mid-way completed and newFNP's MA wondering what in the hell to do.

NewFNP's chronically late but exceptionally gifted MA/phlebotomist finally showed up. NewFNP sent her in with a flashlight and a butterfly to get the sample.

Success!! Winnie the Pooh sticker in hand, she left the clinic with instructions to return in two weeks. Anyone in a gambling mood?

NewFNP continued to see her patients, flashlight in hand, until about 2:30 PM when the power was restored. This is the second time in as many months that newFNP's clinic has had a power outage due to a downed power line. The first time they sent us home after several hours. This time we had flashlights. NewFNP hears that a generator is in the works which, of course, the clinic needs, but damn it if newFNP doesn't appreciate a little unexpected light day every once in a while.

Feliz Cinco de Mayo

NewFNP had completely anticipated a light clinic day today in honor of Cinco de Mayo.  Not so, not so.  Seventy patients in all, 2.5 providers.  

Brisk, right?

On a busy day, why can't all the patients be like newFNP's precocious five-year old who is named after an exotic far-away land and who calls newFNP by her first name whenever she sees her.  

As newFNP turned the corner the other day and saw her in the hall, the little girl screamed "NewFNP!!" and ran towards her - wearing her pediatric paper gown - for a big hug.

"I'm so excited to see you, newFNP!" she exclaimed during the exam room.  NewFNP was intoxicated by her celebrity in the eyes of this little girl.  Granted, newFNP's encounters with this lovely genius are always fun, but newFNP generally only receives this warm a reception when she visits her 92-year old grandma!

Alas, not everyone is so enchanted with newFNP.

NewFNP is ready for a burrito, with salsa verde due to her disfiguring tomato allergy, and a Corona with lime.  Que rico sabor!  

Is 14 hours really enough time to re-group for another work day?  

Five-0

Oh my God, did newFNP ever create one hell of a ruckus at clinic yesterday.

Being a mandated reporter - while important - can be difficult.  Say, for example, when a fourteen year old girl who has run away from home several times and drinks to the point of blacking out and is in newFNP's clinic for a pregnancy test tells newFNP that she doesn't feel safe at home.  And when she says that she is scared of her dad who is, by the way, sitting in the waiting room.  And that she is not scared of him because he is upset with all of her aforementioned behaviors.  And when she finally says that he sexually abuses her.  This four sentence synapsis, by the way, took 40 minutes of listening, questioning, waiting, etc.

So newFNP did what she is supposed to to.  She reported her suspicion for abuse to the local department of children's services who instructed her to call the police.  This is how two, then four, then five, and then seven police officers showed up at newFNP's clinic yesterday.  

If anyone was ever looking for a man in uniform, yesterday was the day to find one.   NewFNP, however, is not in the market.

NewFNP doesn't know if this girl has been abused or if this girl is just incredibly fucked up. Something is not right in her life or she wouldn't be involved in all of the risky behavior she is currently exploring.  It isn't really for newFNP to determine this though - that is for the detectives and the social workers.  

At the end of the day, newFNP cut out 15 minutes early, thinking to herself, "T.G.I. motherfucking F."