And swallow

The Friday before newFNP's grandma died, newFNP was scheduled to see a GI specialist to find out just what in the hell is up with her stupid esophageal pain. Of course, she cancelled that appointment and rescheduled it for yesterday.

NewFNP's handsome, young and friendly gastroenterologist didn't think that newFNP is having diffuse esophageal spasms at all. No, in fact, he thought that she is having eosinophilic esophagitis (EE).

Fucking allergies! This one newFNP blames completely on attending fancy grad school on the opposite coast from whence she hails and where she developed mother-effing food allergies.

Dr. Handsome thoughtfully wrote down a list of foods that commonly trigger EE: corn; gluten; dairy; shellfish; peanuts; and soy. Great. It's like the most anti-patriotic elimination diet ever! No corn? No wheat? No dairy? What's next? No Pledge of Allegiance? And no soy? How is newFNP going to get her salad protein??

Stating that he wasn't entirely certain, Dr. H offered to provide newFNP with an esophagogastroduodenoscopy -- biopsies and all -- to find out just what is the damned problem.

Now, newFNP generally doesn't let a guy put his tube down her throat at their second meeting, but for this guy, newFNP is going to make an exception.

End of an era

NewFNP said goodbye to her grandma this past Sunday. What a wonderful gift to have had her all these years and to have been able to take care of her in a way that honored her life and the extraordinary role that she played in newFNP's life. NewFNP and her brother were by her grandma's side as she took her final breaths and slipped away.

A very special lady, who taught newFNP the fun of shopping and girl time, who indulged newFNP's love of middle school reading with the entire Sweet Valley High collection, who slaved over newFNP's prom dress with her, who loved newFNP equally during her darkest hours and when she was shining her brightest, she will be missed and she will be treasured.

And she will always, always be loved.

Ho no she didn't

NewFNP was driving to work early this morning and it's possible that she didn't entirely have her senses about her. She was driving through an area that is known for being up to no good, but that's pretty routine for her so it was no BFD.

Readers of newFNP know that newFNP considers shopping to be as essential to her life as oxygen, George Clooney and the Sunday Styles. So when she saw a sign for "hoe-tique," she did a double take.

Hoe-tique?! Shitty neighborhood or not, it doesn't seem right that one could just walk in and buy a ho like that! Or maybe they just sell ho accessories such as short-shorts and thigh-high patent pleather boots.

Upon closer inspection, newFNP realized that the store was, in fact, a Shoe-tique but that the "S" had faded over time. Now, newFNP does love herself some new shoes, but she was a little happier when the store was the hoe-tique.

After all, new shoes are a dime a dozen. New hos are harder to come by.

Broken safety net

NewFNP has no problem with HMO's. This is quite likely because newFNP is generally healthy, is in the know, and -- in true newFNP fashion -- has her primary care provider through one of the best medical groups in the nation.

When newFNP went to her PCP and told her that she has been having diffuse esophageal spasms for two years and finally thought it was high time to get that mother-effing upper GI and quite possibly some esophageal Botox, she received her referral before leaving the office and had a specialty appointment twenty minutes later. The system is connected and coordinated.

If, however, you are newFNP's patient and you have a state-insurance funded HMO and you need specialty care, you are jacked.

Take, for instance, newFNP's 31st patient of the day last Thursday. Three months ago, she was told at another clinic that she was HIV-positive. She was told to get HIV care. Where to get that care? Apparently that was not a part of the discussion. Thus, this 32-year old woman showed up at newFNP's clinic stating that she heard we did HIV care.

We do not. Yet.

So newFNP picked up her cell phone, dialed a nearby clinic and handed her phone to the patient who proceeded to make the appointment. Only that clinic doesn't take her HMO.

Son of a bitch.

Yes, newFNP could have gone through the regular old system of giving the referral to the referral coordinator who would get to it as soon as she could given the extraordinary amount of work that she has. Then she would mail the referral to the patient. But the patient wasn't "trying to get no mail from an AIDS doctor" so that option was out. And frankly, this woman had been wandering around for three months out of care and that is just not acceptable to newFNP.

The patient got all of the details regarding the insurance switch she would need to make and then spent some time talking to newFNP about how she doesn't want the HIV meds to make her crave drugs again, about how she can't get state financial aid because she committed a felony while crack addicted and then cried for her diagnosis, for her situation, for her frustrations. NewFNP listened, acknowledged, supported.

She left the room forty minutes later -- five minutes before the clinic was scheduled to close -- and was told by a member of the support staff and HIV planning team, "I thought you were taking care of this!" To which newFNP replied, "What the fuck do you think I'm doing??!" As though taking the time and providing the care to this woman was unacceptable.

NewFNP was livid. And then she went and saw patient number 32.

Bootie-licious

Some things never change with newFNP. For instance, she will never stop looking for the perfect shoes to wear to clinic that are both stylish and comfy.

She found a near bulls-eye on a recent trip to Dolce Vita with her BFF but remarked that she would not want to wear her perfect suede wedge boots if her had to do an IUD insertion. One drop of betadine and that luscious beige suede would be ruined!! She swore that she would remove her new boots rather than take the chance at their being destroyed. After all, there are no surgical booties to cover newFNP's fashionable booties in her clinic.

So of course she headed to clinic last week with her super cute booties and was greeted with the news that the room was all set up for an IUD insert.

Balls!!

At first, newFNP felt a little awkward at the thought of removing her shoes for a procedure and, of course, she shouldn't take off her shoes at work. It's gross, for one, and her shoes offer her some protection from sharps and fluids and god knows what, for two. But fuck that! These boots are brand new and beige suede.

At first, newFNP followed that path of correctness and safety and kept them on, but tucked them under a drape. But she was nervous and couldn't go through with it.

When her patient was in the lithotomy position, newFNP quietly removed her booties and scooted them out of harm's way. The IUD insertion went smoothly and newFNP replaced her boots once the betadine was out of sight.

Thank goodness newFNP was wearing cute argyle socks that day! She would have hated for her medical assistant to have seen some of her B-list socks!!

Put this baby to bed

NewFNP was on her way to work today and was wondering why her steadily moving flow of traffic came to a grinding halt. When she got to the intersection, she saw a person laying in the road with a woman kneeling by her side. NewFNP stopped, noted the decent sized pool of blood under the woman's head and checked for a pulse. Thankfully, there was one and the woman was responsive. She waited until the paramedics -- the super hot paramedics -- arrived and basically put the ky-bosh on well-meaning bystanders trying to move the woman who had been hit by a truck.

That's a hell of a way to start one's day. One minute, you're crossing the street and then next, you're slammed into the pavement.

That's what 2010 has felt like for newFNP and she is ready to put this piece of dump year to bed. Two thousand and ten has been for the motherfucking birds.

NewFNP went about her day, sent a pregnant patient to the hospital with fetal tachycardia, treated another's chlamydia, et cetera, et cetera, and then got a message from the title company that her grandmother's house is in escrow.

NewFNP should be happy about this, what with this economy. She is trustee of the estate and has been wanting to get the home sold for some time now. Selling the house will help newFNP to continue paying for her grandma's care.

But newFNP is a little sad. NewFNP's three-year old footprints are in the cement of that backyard. Footprints from the seventies. NewFNP and her grandma made newFNP's prom dress there. NewFNP has quite literally a lifetime of happy memories from that home -- which, by the way, was built in 1962 and has one of the glorious pink bathrooms featured in today's NYT.

In the past month, when newFNP has gone to visit her grandma, it's clear that her grandma no longer recognizes her -- she just stares ahead as though she is still alone.

The selling of that house feels like the end.

Dis-gusting!

No Monday could be worse than last Monday when newFNP took one to the kisser.

But newFNP had a close second in terms of building her case against Mondays. (And this Monday is in the shadow of a three-day weekend and a newFNP cumpleaños so bitches better start coming correct!!)

NewFNP was going about the same old business of performing a pap. Using her gentle touch, of course, she grabbed an endocervical sample with the cytobrush and, upon removal, noted a viscous, gloopy, stringy mucous hanger-on. Not wanting it to drop, newFNP began an attempt to loop it around the brush using a circular motion.

No luck. A glob of it was hell bent on attack and launched itself Pyongyang style, landing directly on newFNP's forehead.

Fucking. Disgusting.

But newFNP felt like she lucked out by not having that shit land in her eye. She brushed off the attack, literally and figuratively, and went about her day.

Hit me with your best shot

NewFNP has had better days at work.

To begin with, newFNP's back is jacked up and she is walking like she has a stick up her ass. Then she saw 17 patients before lunch.

Then her last patient hit her in the face. Open hand, but with the force of 202-pounds of mother-fucking crazy behind it.

NewFNP has never, ever been hit before. She is a white girl from the suburbs who went to top tier schools and watches Jon Stewart and goes to spin classes and shops at J. Crew. She does not engage in fisticuffs. And, quite frankly, she could go the rest of her life without ever being hit again if she has her way. It hurts. NewFNP was actually dizzy. And she was completely fucking shocked.

After her patient was forcibly removed from the clinic 5150-style and newFNP spoke with the officers about her being a victim of battery (not her words, but noted on the very official police report), she was told that she should go home for the rest of the day.

No shit.

It's one hell of a way to get half a day off, but you don't have to tell newFNP twice to get the hell out of dodge. Why couldn't her patient unleash the crazy at 9 AM instead of at 12:30??

Hipst-astic!

If there is one thing that newFNP sees very infrequently at work, it's white people. And today newFNP had a white hipster (subtype 70's-inspired) in her exam room.

He looked as though he had rolled straight out of Williamsburg on a fixed-gear skinny-tire bicycle while listening to Deerhunter and had somehow managed to end up in newFNP's clinic via some kind of fashion/anti-fashion vortex.

He had many of the markings of hipsterdom:

- shaggy hair-do and beard

- tan corduroys and a plaid tan & white shirt a la Oliver from the Brady Bunch

- American Spirits

- canvas Aasics

- a college degree yet a job at a camping store (possibly related to the economy and not hipsterdom)

- understated ennui.

How did he find newFNP's clinic and end up in newFNP's exam room to discuss the communicable scourges of scabies and HPV? After all, her clinic is in a very non-hipster and seemingly ungentrifiable area of town.

In his honor, newFNP is listening to her Hipster Harvest Mix CD, courtesy of her BFF, and laughing once again at the hipster dinosaurs.

Tech Talk

As we all know, the DSM is getting a do-over. As the NYT pointed out today, narcissistic personality disorder is on the chopping block.

Well, newFNP can help pad those empty pages. She is here to offer a new criterion for "psychotic disorder NOS" that should make it into the new psychiatry bible.

NewFNP is a fan of technology helping her out throughout the course of her workday. Where would she be without her iPhone and its BMI calculator, its OB wheel, its ICD-9 coder and its access to her gmail account so as to enable newFNP to track her online package shipments while at work? (Damn you, Madewell, and your cute new sweaters for 25% off!!) NewFNP's clinic is en route to electronic health records and newFNP is very much looking forward to forgoing the search for a decent black pen every day.

But these technologies are not those of interest to newFNP in regards to her hypothesis of how technological advances are shaping the scientific and clinical milieu.

NewFNP has noted time and again that people who are somehow psychotic attribute profound significance to the shitty photos snapped on their cell phone cameras.

NewFNP has seen many, many a flip-phone and Blackberry image and has been told that the image in the blurry photo of a sex partner was the aura of a snake, that there was a hand coming out of someone's head, that there were angels reflected in the mirror. In each and every photo, newFNP saw essentially the same thing -- a crappy, blurry cell phone picture utterly lacking in reptiles, odd appendages or the supernatural. And she can say definitively that the more expensive phone did not take a better crappy ass picture.

In one patient, newFNP gently asked if anyone had ever told him in the past that he may have a mental illness? No, he told newFNP, he was a Christian and he had burned the curtains in the living room after having sex with the snake-aura partner in order to purify himself. His response did not diminish newFNP's concern.

Perhaps the criterion can be "On at least three of the past seven days, the patient has engaged in excessive cell-phone photography (excluding those on iPhone 4 with flash and photography apps) and has inappropriately placed religious or spiritual significance on the incomprehensible images attained."

You're welcome, APA. You get that one for free.

Family Tradition

The first time newFNP saw positive cerebellar findings in a chronic alcoholic, she thought that the patient had misunderstood her instructions. Not that rapid alternating movements (RAM) are so hard to describe, especially as newFNP always demonstrates said movements, but -- you know -- maybe the patient just missed the boat.

In retrospect, she shouldn't have been surprised. This patient was a middle-aged man who walked as though he was an epileptic zombie. Yeah, that gait ataxia is a good first clue. (This video of a professional man in pleated Dockers-style pants demonstrated a pretty great example of ataxic gait and, frankly, is kind of hilarious.)

Yet, newFNP was astonished to see the floppy-fish movements of the RAM. When she moved on to finger-nose-finger (at a arm's length away of course -- any yayhoo with half a cerebellum can make reasonable contact as less than full extension), she felt lucky to have left the room unblinded. She didn't even conduct a Romberg as she felt concern for the patient's safety.

That was about a year ago when newFNP was in the research clinic. That patient did not matriculate into the study.

Today, however, she had a patient in his mid-40's who began drinking at the age of 12 when his drinking buddy was his father. Having just been released from jail, he came to see newFNP to refill his diabetes meds. The last time she saw him, newFNP noted that he smelled of alcohol. This time, he lacked the aroma but exhibited the slurred speech one might note with acute intoxication. The dysarthria reminded her of her patient with cerebellar ataxia some time ago. His neuro exam confirmed newFNP's suspicion of cerebellar injury.

Now, newFNP loves her wine. And her mojitos. And her Maker's Mark with ginger ale. Wait -- where was newFNP going with this??

Ah yes, alcoholism is truly devastating. This man cannot work, he is in and out of jail and his father died from the disease that is killing him as well. The last two times newFNP assessed his readiness to change his drinking behavior, he was very clear and straightforward -- not ready, not yet. Since leaving jail this time, he has been drinking very little. He states it's time to get straight.

It's just too frigging bad that his cerebellum has been pickled before he came to that decision. Perhaps he will see some improvement if he can achieve some sustained abstinence. Until then, newFNP gives him his multi-vitamins. Today he got prenatal vitamins -- they were all newFNP had to give.

For other clinicians and students out there who need help getting substance abusing patients into care, the SAMHSA Treatment Locator is super helpful.

Grammar

Once upon a time, when newFNP was a younger lady and a new MPH student, the most influential professor of her life taught her a valuable lesson: data are plural.

This is certainly one of the least important lessons she learned from this professor from a public health perspective, but is one newFNP very commonly reflects upon given the frequency with which it is ignored. It has served newFNP well over the years in her academic writing and conversation, but it has also served to drive newFNP to drink when she all too frequently hears public health and medical professionals say "The data is..." It's like nails on a mother-effing chalkboard to newFNP.

As newFNP was sitting in her providers' meeting today (number of productive minutes = 7; number of minutes = 120) and hearing the noun-verb mismatch over and again, she was thinking to herself, "Thank you, SBS, for preventing newFNP from committing this academic faux pas... and thanks a lot!"

Do that voodoo that you do

One of newFNP's struggles is to work within a culture that is so utterly different from that of her own. Generally that manifests in requests for disability paperwork or in the dramatic vocalization of pain.

However, this struggle became uniquely salient today as newFNP was completing a physical on a 41-year old man. While he has a partner and family in his home country, he has been in the U.S. for twelve years and has a partner here as well. Apparently, his original partner was none too pleased because, as he told newFNP, she put a curse on him in order to make him impotent.

And dammit, it worked.

Now, newFNP might have taken an educational trip to a forbidden island in which voodoo is practiced and she might have entered an apartment which was protected from the evil eye by a special red fabric and was receiving some kind of power from a chicken with its legs bound by a red cloth, but that is as much as newFNP knows about witchcraft and black magic and voodoo -- which is to say she knows nothing. At her fancy nursing school, they wanted to teach the students frigging Reiki, but not even an elective on traditional/cultural medical practices/voodoo? Way to be culturally competent.

NewFNP could find no physical health concern that would explain this young, fit man's ED. From his perspective, his health was non-contributory.

NewFNP probed for a psychological explanation. Was he perhaps feeling guilty for having another partner here? He stated without equivocation that he was not.

(Hell, who can blame a dude for finding another lady after twelve long years? NewFNP is having a dry spell that nowhere near approximates that - thank god - and she's considering some recidivism.)

She asked him if he would like to try Viagra. He did not, because as he explained, the problem rested in the curse.

Not sure where to take this encounter, newFNP asked him if he believed that her curse was the only cause of his erectile dysfunction. He was certain that it was. In that case, newFNP told him, it seems as though you need to find someone to reverse that spell.

And for that, newFNP is hard pressed to recommend a single practitioner.

Thanks, but no thanks

It was placenta. The patient is fine albeit somewhat peeved.

In her follow up visit, she told newFNP that when she first felt something falling out of her lady business, she called her husband into the bathroom to survey the scene as she was unable to see beneath her newly post-partum abdomen. He confirmed that there was, indeed, something gone quite awry and that there was most certainly something alien in her nether regions.

"Pull it out!" she instructed him.

He declined and, instead, brought her into the clinic.

For those who are interested, the AAFP has a decent article about how to evaluate whether one has actually accounted for the whole thing. The article is a bit old, but newFNP doesn't think that the placenta has changed much in the past twelve years.

Contingency management

NewFNP deals with a lot of vaginal complaints. They generally run along the lines of itch, olfactory woes or a forgotten objet causing distress and/or one of the aforementioned concerns.

What is exceedingly uncommon (n=1 in five years) is for a woman, three days post-partum, to present to clinic with a chief complaint of "something is coming out of my vagina." NewFNP had two differentials: retained products or prolapsed uterus.

As newFNP and her patient assumed their respective positions, newFNP briefly thought, "Holy mother, is that an umbilical cord??" before coming to her senses. What she saw was a shiny, slimy, veiny mess with a decent sized clot in the middle of it, discovered only by digital exploration of said mess. NewFNP admits that she was surprised at the absolute lack of vaginal bleeding given the situation.

"Placenta," she thought. "Now what?"

NewFNP gave the protruding mass a gentle tug. Nothing moving and no pain on the patient's end. A slightly more forceful tug elicited movement but nothing spectacular. At this point, newFNP brought in Dr. Dual-Ivy-League-Degrees for assistance. While newFNP maneuvered the speculum around the protruding mass, Dr. Dual-Ivy-League-Degrees tugged with the ring forceps. Again, nothing. Not wanting to cause a hemorrhage and noting increased vaginal bleeding and that the patient's pulse was 120, newFNP and Dr. Dual-Ivy-League-Degrees stopped their efforts and called for an ambulance.

NewFNP probably could have handled the entire situation alone, but was just too uncertain. If the patient had been hemorrhaging and had something protruding from her vagina, that is an entirely different call: get whatever is causing the problem OUT. But this was different and newFNP just hasn't managed post-partum complications such as this in the past.

What a great learning experience for newFNP, both in learning about the actual care of this patient and of trusting her knowledge and feeling confident in her care.

Hasta la vista, toenail!

For five long years, there has been nothing that brings the quease to newFNP's stomach more than the very thought of removing a patient's ingrown toenail. NewFNP has used evasive maneuvers to avoid having to learn the procedure thus far, but now that she's signed on for another two years in the trenches (two months down --holla!!), she figured that she might as well jump in completely.

So she took off a toenail today and it was just as gross a procedure as she had expected. It is very tactile in that the remover can feel the nail tearing from the bed via the kelly clamp. And that tactile sensation did nothing to quell the quease. To top it off, newFNP can only imagine how awful it must be to have the procedure done and that made her feel even worse.

But she didn't pass out or barf on the patient's foot, so newFNP is content to call the procedure a success.

Consumption

The New Yorker is tailor-freaking-made for newFNP this week. A Talk of the Town piece about Pavement (you can bet newFNP has her tickets!!), an article about FB, another about Tavi and an article about J. Crew!! When in the world will she find the time to watch Sons of Anarchy??

But newFNP's life hasn't been all fashion and literature and hot, swaggering, conflicted motorcycle club VPs.

She has blissfully received one day of pediatrics and women's health in the midst of her grueling internal medicine and outpatient OB schedule. Except that life is not to blissful when one sees a 22-month old kid -- in the U.S. for four days -- with hemoptysis, such that his little jeans are covered with blood, and right apical rales that are gurgling to beat the band.

He had been in clinic two days prior and had been treated for a severe stomatitis. While the mom did note that he had the hemoptysis, the other provider treated the stomatitis and placed a PPD. The PPD was, as one might expect, stunningly positive.

It was no great stretch for newFNP to mask that sweet boy and send him to the emergency room after explaining her concern for active TB to the mom. And, of course, there this little boy remains, on oxygen with fulminant TB. It's hard for newFNP to imagine that those apical rales weren't present two days prior, but it's always easier to see things clearly in retrospect, is it not?

Mondays with Grandma

NewFNP's grandma is ninety-five. She has been demented for quite some time and this makes visits with her really difficult.

But lately, her health has been worse and, conversely, her cognition has been clearer. It's a gift to newFNP, but makes newFNP wonder how much longer she has. Last Monday, newFNP was snuggling with her and crying when her grandma pointedly and caringly said, "Honey, I don't want you to cry for me."

Today, newFNP was holding her hand when her grandma looked into her eyes, tears rolling down her smooth cheeks and said, "It's too hard to... it's too hard to..."

NewFNP said asked her what was too hard, even though she knew.

"It's too hard to say goodbye," her grandma whispered and then closed her eyes.

And it is. It is a fucking nightmare to say goodbye to someone you love so dearly, ninety-five years old or not. As her grandma slept, newFNP spent hours quietly sharing memories, offering words of peace and watching the gentle rise and fall of her chest. She held her hand and kissed her forehead before she left for the evening.

Bon anniversaire!

NewFNP celebrated five years of being newFNP today by hitting an 8AM spin class -- her first spin class in a year. Yowza.

A lot has changed in these five years. All of her friends from nursing school are married and most have kids or are pregnant (hooray nycPNP!!), whereas newFNP is bordering on cougardom. She has lost some of her closest loved ones and has gained others. She has visited three new countries, had three major hair-do changes and is on her third car.

But newFNP's most significant change is that she is confident in who she is as an NP. She is continually challenged by her patients, by working in community health and by keeping herself well while working in a dysfunctional environment.

But she is learning and she is capable. Just this week, newFNP diagnosed erythema nodosum and nephrotic syndrome -- both just known of but never seen differential diagnoses until now. That feels quite good. She saw what she thought might just be chancroid, which to hear newFNP's patient tell it feels not at all good, but might feel better after a change from acyclovir to azithromycin.

Now all newFNP is left to contemplate is where is this little endeavor -- the one you are reading -- going to go next?

Thank you sir, may I have another?

Remember the joy newFNP felt when she received her letter of completion from NHSC? Lord have mercy, she signed on for two more years. By the time newFNP finishes her loan repayment contract, she will have had seven crazy years at her community health clinic and $50,000 less debt.

NewFNP imagines that the phrase "seven-year itch" will take on a whole new meaning.