Friday, November 18, 2011

super vaccine?

Most creative question of the day;

will my flu shot prevent dengue fever?

- hmmm, wish we had a super vaccine, but this only includes three strains of influenza protection, kudos on the interesting question though :)

Thursday, November 17, 2011

it's a digital world...

Saw a lovely twenty something new dad in the clinic today, walk-in visit for Tdap to protect his sweet new son against the woes of pertussis... asked for a photo of the baby, and was treated to a video of his scheduled repeat C-Section birth. Wow... in all detail. As a former labor and delivery nurse, I felt honored to share in the viewing, and also quite struck at the place that digital recordings have come to take in our lives and in medicine. I'm sure the Mother greatly appreciated Dad's recording so she could re-live the action on the other side of the OR drape later.. and I feel special to have been offered a peek at the special moment as well.

Friday, October 14, 2011

not what she said...

you may remember a prior post on selective English T-shirt wording which patients sport unbenounced to the actual meaning of the wording.

Today, I saw another choice example of why an English-Spanich Diccionary may come in handy at your average San Francisco thrift store;

Walking on the corner of 19th and valencia, a kind tiny older hispanic woman was seen sporting a shirt reading "expert cougar hunter".... hmmm, something tells me the meaning is lost on her, and i expect her cougar hunting skills are minimal if at all existant :)

Not clinically related, but thought it was worth posting before the weekend to put a smile on a few faces!

Monday, October 10, 2011

resources shmescources

This NP was recently seen at a large conglomorate hospital in the area (think socialized albeit private quality medicine with a name that correlates), using insurance I have paid for through work although I waited over 90 days for it to "kick in", I was seen for a procedure (which luckily amounted in nothing abnormal, yeah!). The experience reminded this provider how broken our medical system is.

Patients are usually not seen in Community Health Centers by choice, and there is a reason why... understaffed, underfunded, with long lines and limited resources... (although to be fair; our spunk, drive, commitment to social justice/equality,creativity, and NHSC obligations are second to none!)... it's nothing like a trip to your friendly concierge service MD.

While a friendly radiologist inserted an uncomfortably long and shockingly low gauge needle into my neck, a friendly radiology tech followed instrutions on a quality ultrasound machine, and a very peppy tech complied with the provider's every need. Wow, posh... and it was only a relatively minor procedure.. I've put in hundreds of IUDs (a sterile procedure nontheless) singlehandedly without even an MA, so this treatment felt like a day at the spa (medical-resource wise).

Ok, I'm not saying we should all be signed up for some high priced, private HMO...and if you are a billionaire and want to use some of your wealth to pay for an ultra-private service, so be it... what I am saying is that every citizen, from the uber rich to the hoi polloi deserves basic, quality, accessable and appropriate health care as a human right... you can always pay extra to access your botox, fancy additional procedures, or brand name medications without generic equivelent, but there is something majorly broken when such huge disparity exists.

I don't have all the answers, but the basic starting point seems quite simple... it's broke, needs fixing... start at the beginning; basic affordable health care access for all.

Folie à deux

Folie à deux, "a madness shared by two"... not exactly a classic case, but remarkable nontheless...

Working triage today, a patient walks in requesting a medication refill... normally this involves review of a patient's medical record, but given he is a new patient, it would involve patient subjective history, a pharmacy med list, or prior medical records.

A list of common question/answers ensue; with one commonality... see if you can spot it;

"what medication" - not sure
" what for" - not sure
"who prescribed it" - not sure
"where was it prescribed" - not sure
"did you bring a list or the bottles" - no, I lost my backpack which they were in, not sure how or where
"how long have you been off the medication"- (no joke) one hundred weeks
"one hundred weeks is over a year..." - well, at least since August (August was two months ago)
"do you know the month/year today" - got this one spot on!

ok, so we were not getting very far with this questioning. A set of vital signs later ensured that the patient was at least not going to drop in the office, saving us some time for investigation.

"so", I commented "there seem to be a lot of details you aren't clear about, can I ask who helps you remember to take your medication?"

"Sure" he replied "my friend steve or my mom"

Excellent, this NP thinks to herself, I may be able to solve this case yet!

"Can you bring your mom or Steve to the next visit?" I inquire.

"no, they are REALLY crazy" our fairly confused patient comments... ahhhh... Folie à deux

Hopefully our lovely social worker will be able to make heads or tails of the case next week, as I called EVERY major pharmacy in the area, and no record of this kind patient exists.

gotta love the creativity of community health, and the opportunity to occasionally feel like your life is a strange movie that never ceases to somehow entertain...

Wednesday, August 24, 2011

the dreaded refill

the refill process in the USA seems to baffle the majority of community clinic patients (at least in this Latin American community provider's experience). Although I have educated patients in the refill process, helped them call the pharmacy, handed out copious refill instruction sheets, and scheduled visits with social workers and nurses to educate on the refill process, clarifying literacy and other obstacles to refilling much needed medication... the issue still persists. Most recently, I started a campaign with the intake staff, to ask patients if they needed a refill, and instruct them how to 1) call their pharmacy and 2) check if they have a refill available prior to requesting a clinic walk in visit for a refill request.... this seemed to help, for a while, but now the requests are back again.

Some days in health care, I feel like a parrot, repeating the same phrases over and over and over again.... maybe I need to invest in a video production studio and instead of prescribing medication, prescribe an instructional video at the end of each visit... hmmm, that's a thought.

Saturday, August 6, 2011

the wolves within

As I have stepped deeply into management/leadership this year in a department which required a great amount of change in order to offer excellent patient care and a positive work environment, I have leaned on the power of story telling. It's amazing how people come together around a common story theme, and can really connect to the meaning of the tale... this is a favorite of my staff;

An old Cherokee is teaching his grandson about life. "A fight is going on inside me," he said to the boy.

"It is a terrible fight and it is between two wolves. One is evil - he is anger, envy, sorrow, regret, greed, arrogance, self-pity, guilt, resentment, inferiority, lies, false pride, superiority, and ego." He continued, "The other is good - he is joy, peace, love, hope, serenity, humility, kindness, benevolence, empathy, generosity, truth, compassion, and faith. The same fight is going on inside you - and inside every other person, too."

The grandson thought about it for a minute and then asked his grandfather, "Which wolf will win?"

The old Cherokee simply replied, "The one you feed

consider; the clinic/hospital/environment in which you work is also the place you are LIVING in... regardless of what you return home to, or what you enjoy after hours. Your words are powerful, in your life, your staff's lives, and your patient's reality.. use them with impeccable caution and create with them the reality you want to live in. It's that easy (and that difficult).

calling all critics

what topics/comments do people want to see covered here?

Normally, I wait until an inspiring day to recount long lost stories of community health that come to mind.

Are there topics people prefer me to write about?
Particular questions or situations I can add my experience to?

let me know :)

Onward community health peeps.... you're a rare breed, but the world would never be the same without you!

Thursday, August 4, 2011


Morado; Spanish for purple.. the concord hue beloved by many, and a lovely accent for almost any skin tone when use appropriately.... today, While admiring an elderly patient's carefully coiffed lavendar curls I was reminded of the good bad and ugly of the color purple and it's application to community health;

Gentian violet...aka "crystal violet", no, it's not a new urban form of Meth, but an inky dark fluid just this purple side of indigo.... some science geeks (myself included) may remember this lovely substance along with iodine tipping us off to the leakage of starch through a plastic cellulose "baggie" immersed in water during a freshman biology lab (osmosis anyone?)... my patients, on the other hand, apply this willie wonka fluid liberally to ANYTHING that might need curing/disinfecting/fixing/healing/younameit.

I have seen bright purple fingers, patches on limbs, cuts, and burns.. but only one purple penis. Yes, that's right, penis.

I will never ever forget the day that a kind elderly Senor stepped into my office, complaining of a problem with his "parte"... when he presented said "parte" it was stained a bright purple that only meant one of two things; extreme emergency, or case of purple violet dye. "Sir" I asked in spanish "did your penis start off as purple or did you put something on it". I breathed a sigh of relief as he described application of Gentian Violet due to an itchy rash he had experienced the prior week. Return to clinic the following week, and d/c application of lovely purple stain in the meantime revealed classic case of balanitis.... that had been covered up by all shades of glorious purple.

lost in translation

You have to appreciate the Bilingual humor that so often comes with practicing medicine in a community clinic… consider, when one decides upon the final characters for a chinese tramp stamp, before signing on the dotted line, I highly recommend bringing along a friend fluent in Chinese. This can be ever to helpful to prevent accidental life long imprinting of “idiot” or “fatty” instead of the tranquil “longevity” symbol theoretically offered. The same concept is true when purchasing brightly colored T-shirts at a local thrift shop…they may cost $1 in the bargain bin, but unless one is versed in the language imprinted on the T shirt, proceed with caution.

I have fond memories of a lovely Oaxacan patient who came to the clinic in a tight white baby T imprinted with bling bling gold and rhinestones spelling out “That’s right, I’m the bitch” across her tiny chest. This soft spoken Indian woman had NO idea what she was projecting to the world, and my kind MA took a few moments to explain this to her. Crestfallen, the sweet patient opted to leave wearing her shirt inside out. This experience was brought to memory today when I saw an older Hispanic gentleman perusing the halls of the clinic, shade of his sombrero barely obscuring the “Michigan Flip Cup Champ” T shirt he proudly sported. Something tells me this Senor has never played a game of flip cup in his life, but who knows.. maybe he’s developed new skills in a new land?

Wednesday, June 22, 2011

advice to the neophyte

in response to a recent comment from Neophyte NP as to what I would tell recent grads... especially for a more mature graduate that is completing her clinical soon.

here goes a stream of consciousness reply to that post (as I cannot apparently reply with anything longer than 4000 characters, i will post it here!)

basic things that come to mind;
- choose your own clinicals... focus on places/jobs that mirror those you would like to consider (and if you're not sure, then choose a variety), finding your own preceptors ensures that you have a placement where you learn from your preceptor, and experience the work environment/patient set that you will need experience with for the future. Much of what you learn in school is learned in clinical, make the most of it. A tip: talk with students that are one year ahead of you (or one semester) and ask about their clinicals... find preceptors that other students love and ask in advance to be recommended to work with that preceptor next semester (I found most of my precptors this way)... another idea; talk with professors you highly respect (well in advance) and ask to do a clinical rotation with them (be persistent!). It's a good idea to either work a BUNCH of days at one site in a row, or to spread your clinical over regular days at the same site... thus you can either get a feel for a LOT of work flow at one time, or get to follow up with your own patient "panel" during clinical. Consider daily topics with your preceptor... choose common disease topics, pediatric physical age sets, or the like, and discuss for 15 minutes over lunch... often, you can choose the topics in advance, and then you can present the topic to your preceptor over lunch, this gives them a chance to add their two cents at the end, and to review their own knowledge base as well! I'm a proponent of the idea of NP residency, but until this occurs, chica, your clinicals are your residency before the trial by fire begins on your first day, so make them your own, it's your last chance to control where you work/what you do!

good sites for preceptorships;
- community clinics
- planned parenthood
- other sites where your friends have really enjoyed their clinicals
- specialty sites you might consider working in the future.. give it a try before you commit!

other things to remember... you are 48, I consider experience to be a good thing (and it freaks the patients out less.... after all, I'm 31, but patients often ask if I'm 19, not exactly ensuing confidence from the first visit, lol). When you are new, you will have to ask a lot of questions/look up a lot of stuff/ take a lot of NSAIDS for the headaches this will cause (lol, no seriously....)... each day, you will answer another question that you will then know the answer to the next day... after a while at the job, you will be a pro (really, you will) and you won't have to ask those same questiona again, you will remember the basics, and look up the rest, I promise!

Funding; consider the NHSC (National Health Service Corps) their loan repayment program is way easier to get approved than the scholarship program, and it's a great way to get your feet wet in the community, while getting loans paid! Also, community clinics are often more eager to hire NPs right out of school (even before that pesky furnishing license has been earned!).

things to learn now; schools don't often teach about medical coding/billing and proper paperwork/NP practice protocols for clinical work. Clinics REALLY don't know about them... so take the opportunity to rack the professorial brains and preceptor opportunities available to you now (learn how to fill out an encounter form/super bill, play with electronic health records), ask your professors how to write your own standardized procedures, and what your state regulations are... trust me, most clinics and clinicians don't know how to write paperwork for legal NP practice, and most med students don't know HOW to fill out a billing form (even though doing it wrong actually constitutes fraud... and frankly, it's our bread and butter to keep the doors open).

well... phew, those were my initial thoughts that came to mind under the "what I wish I had known" category.

Good luck neophyte, soon you'll be an oak tree :)

Thursday, May 5, 2011

mail order what?

40 year old Norcal skate border walks into the office with a bright teal fiber glass cast on his left arm.
"Nice color choice" (I compliment his Orthopedic fashion consciousness)
"you may not think so after you hear this...." he begins.... it is a tale that would make even the staunchest Tea Partier deman universal health care: lost his job as a master's prepared Engineer , got a new job, new job doesn't offer insurance.... new job makes TOO much money to qualify for local health assistance, but not ENOUGH to afford an ER trip. So... after he breaks this arm for the seventh (yes, seventh) time during an extreme skate boarding routine, so what's a smart skateboarding engineer to do....??? He pays privately for xrays, interprets the xray himself ("it didn't look too out of place..  I think it was the scaphoid process...I did a lot of googling online").  Then, industrious as he is, the patient orders online casting supplies "they came from Pennsylvania, I had to wait a few days for them to arrive"... upon arrival, he leans his skateboard against the wall and undertakes a self casting process (good thing his dominant hand was spared this time!). 8 weeks later, he cuts open his own cast, and duct tapes (see prior uses of duct tape) it back together.. peeling the shell off to allow the radiology tech to x-ray his self-healed arm.... still shows a break.... so back on with a new cast. In the meantime, he's found a new job, one that pays less, so he is now ELIGIBLE for the city assistance program.... but needs an Ortho referral to be seen.... which is what brings him around, full circle to my office.  Ortho referral given... urgent visit scheduled by spending one hour on the phone trying to reach the Ortho NP, who, aghast like myself, double-booked this kind skateboarder for an urgent consult tomorrow.  After all is said and done, and the urgent double-booked Ortho consult inevitably results in tax dollars covering a percentage of an expensive prior-unnecessary surgery.... we will ask ourselves (or at least we should) why health care is not treated as a Human Right.  I would insert excerpt here about a favorite friend of mine who has similar ortho and issues (self-casting aside)... a full-time working, college educated, amazing contributor to society and my life who will likely pay out of pocket to have her lovely dancer's wrist surgically repaired after falling from a scooter.. but honestly, I'm just too pissed off to write more in this moment.

All atrocious health insurance policy and indecency aside teal was a good color choice..... that much is true!

Monday, April 18, 2011

not that kind of plumbing....

26 year old patient walked in today, mentioned he had something "down there" that hurt very much for 3 days, and wanted me to take a peek. As a rule, I never refuse to look at genital lesions and simply re-schedule, even in urgent care, no one wants to miss a new case of HSV that can quickly response to antiviral treatment.... and no poor soul wants to wait even 12 more hours before at least a presumptive diagnosis and routine STD testing is offered.  Apologetically, this patient lowered his drawers, while explaining "I put some tape where it hurts so it wouldn't rub on my shorts...."

Low and behold... in all its glory, silver duct tape wrapped from pubis through perineum.... I truly thought this   guy would demonstrate a self-Brazilian just short of castration during removal of the 10 inch strip of duct tape stuck to his nether regions....

Due to application of super-sticky-duct-tape.... any previous appearance of the painful "area" was now obsured by a hyperpigmented slightly greenish color that left this NP dumbfounded. A consult with friendly physician later, and we were both stumped... threw some septra and clotrimazole at the offending "lesion" and I kindly offered up some telfa pads and paper tape for any further "chafing" needs...

final diagnosis TBD.... (threw in routine STD screening for kicks).

Moral of the story; just because it duct tape is good for most things doesn't mean it's good for EVERYTHING.... no, really!

Wednesday, April 13, 2011


First week on new job in urban community clinic... reception alerts me at 4 pm that there is a patient in the hall way crying.  Broken down in a sad corner of the waiting room, I find "Jane".... obviously in a state of heroin withdrawal disarray, curled into a sad little tear filled ball.  I carefully lead Jane to the nursing office for assessment.

 Turns out this lucky lady is presenting with one huge abscess, worthy of incision and drainage and regular wound care follow up. Good thing that in this urban neighborhood, there is a public outpatient clinic catering to just such skin care services. "Great, this will be easy", I think to referral later, and she can walk in tomorrow morning at the outpatient wound clinic.....

Jane needs ID in order to register as a patient, her only ID is a birth certificate which she cannot find, thus, I begin to aid her in the search for said certificate.  A fascinating experience ensued; if you have never seen the contents of a homeless junkie's backpack,  I highly recommend it.  Amongst newspapers and a hooded sweatshirt of questionable cleanliness were unique talismans, random bits of paper, a few religious iconic cards, and one crumpled, stained birth certificate!  I leave the room, birth certificate in hand to register and refer, with a plan to give some IM antibiotics to stave away the infection until surgical attention tomorrow morning.

Upon returning to the room, Jane has "perked up" quite a bit... enough, in fact, to have taken advantage of all the hospitality an exam room can offer.  I find her standing in front of the sink, her gaunt silhouette accented by fluorescent lighting, and not a SCRAP of clothes on her buck naked body.  She smiles at me confidently while returning to the task of scrubbing her dress in the sink.

Sigh... although this NP appreciates good hygiene, a pre-laundry plan includes  an extra set of clothing, or at least a robe or towel... none of which the patient had thought through prior to plunging said dress into hand sink and dousing with several vigorous pumps of hand soap.

What to do.....?

Several phone calls to shelters, clinics, and homeless resource programs later..... no clothes to be had.  A few minutes later, one kind security guard offered a clean pair of boxers from his locker... bottom of "situation" covered.

 Jane has the final solution.... "I have a hooded sweatshirt that covers the top... it's almost like a dress because I'm so tiny, and anyway, my legs are my biggest asset"... a sweet shot of Rocephin later, a boxer/hooded sweatshirt clad Jane, headed out the door red biohazard laundry bag in one hand, and referral in the other...."biggest assets" in full display as she pranced through the parking lot.

Wednesday, March 30, 2011

the chester sign

When this NP used to work in migrant health care pediatrics, we would commonly see kids walk in the door toting 900 cal. bags of spicy hot cheetos (with GERD producing lime and chili ADDED to the bag)... when parents and kids complaining of uncomfortable gastritis adamantly declined eating these red and orange tinged snacks.... brightly stained fingers would often chip away at such claims. One pediatrician I worked with jokingly called this bright orange evidence "positive chester sign" .... as in

S; c/o abdominal discomfort
HPI; approx 3 weeks with abdominal discomfort, worse after eating and on empty stomach,
ROS; denies V/D but does report occas nausea. No fever/chills. Denies eating any spicy or fast food, including spicy hot cheetos
O; bright orange tinged fingers.......positive chester sign
A; dyspepsia with evidence of CHEETO CONSUMPTION
P; no more quarters for the vending machine... cutting you off of red dye #5

a new article links hyperactivity and artificial food dyes, all the more reason to lay off the cheetos (and the chester sign will give you away if you don't!);

Friday, March 25, 2011

dirty little secret

Afrin... a dirty little over the counter secret that many patients keep to themselves.. use this nasal spray once or twice in a 48 hour period, and sweet vasoconstriction will relieve your drippy faucet of a nose for a few hours... but use it past the 48 hour period, and a flood of rebound nasal congestion will leave you drowning, gasping for more Afrin to stem the tide.

Medical diagnosis; rhinitis medicamentosa (too much afrin use is causing rebound congestion, resulting in your nose to ceasing to be an orifice capable of breathing) 

What to do about this? STOP USING THE AFRIN. Also, start using an appropriate prescription only nasal spray (fluticasone is cheap now, yeah!!!!) and, although debatable, I have found that a short burst of oral steroids (consult epocrates and up to date here folks) can be helpful in transitioning the Afrin lover during the withdrawal period of rebound congestion. It's also important to remind the patient to only use their new nasal spray as directed, as many assume that more of a good thing is an even better thing.... not the case at all.

Addendum; saw a patient today complaining of "I have a loss of flavor in my mouth" (I swear those are his words)... after I pondered for a moment, i said "are you congested" (yes), "do you use afrin" (yes).... ahhh, what a brilliant dignosis.

Thursday, March 24, 2011

stay sexy...

It's official... sex can kill you:

one more reason to stay fit... apparently being sexy before engaging in sexy time can safe your life.

big surprise there.

If you're not going to stay fit, then make sure to have enough sex.... so your ticker isn't caught off guard, kind of like the "weekend warrior" syndrome during Wednesday night business time;

Thank you Flight of the concords for keeping us sexy, or at least, helping non-sexy people somewhat reduce the risk of cardiovascular events by creating a regular schedule for business time;

sign language

As most of my patients are exclusively Spanish speaking... I often play a funny little head game of speaking in Spanish while writing in English simultaneously during each visit... I like to think of it as my mental training to stave off Alzheimer's well before its time. This being said, it's rare that I speak English with a patient, and often find myself translating my common "medical discussions" from Spanish to English in my head as I spout of frequently used patient education, medication instructions, the occasional diabetic threat and the like. 

Yesterday, I had the unique opportunity to examen a patient who spoke no English or Spanish.  This was a lovely Turkish patient, who was complaining of cold symptoms. This patient arrived wearing  hijab with a floor length black non-descript coat, and a dark head covering  and I was immediately conscious of respecting the personal privacy such attire suggested.  At her request, the kind son translated the subjective portion of the visit, but the exam involved slight disrobing, and thus, son was kicked to the waiting room till the diagnostic portion of the visit.  

In community health, it's best to ask patients to bring all their bottles to the visit... resulting in large crumpled plastic bags, totes, and coolers full of random pill bottles which the provider arranges precariously on the side of their desk, attempting to create a med list from nondescript worn labels and foreign medication names ... but hey, it beats "I take a green pill for blood pressure sometimes, and a birth control pill in a pink box" which is the normal "med list" we can otherwise expect.  This patient had brought her pills with her, true to our request... and when she pointed at a bottle of thyroid medication, she then looked me in the eye tenderly, and pointed at my neck and then hers. 

Caveat... this NP is a thyroid cancer survivor, a badge I proudly wear, and truly do not mind the frequent inquiry as to the origin of my thyroidectomy scar (albeit.. if the comment is along the lines of "why did you try to kill yourself like that" or "are you in a cult"... both of which I have heard several times... my answer will certainly be directed at directly embarrassing the ignorantly inquisitive small mind behind such questioning). 

As I pulled open the black fabric of my patient's covering, I noted the same thyroidectomy scar... sisters in experience... we gave each other a hug, and a kiss on the cheek, and embraced for a few moments, before, with a deep sigh, settling into a visit of no words, many gestures, and a deep shared trust. A positive strep test, and some amoxicillin later, she was on her way.... and I was left with the kindness of her gesture and a deep sense of place, satisfaction, and acceptance. 

These are the moments I love my job... when the unspoken language between two people is so audible, it is impossible not to hear and connect to the essence of being human.

Friday, March 11, 2011

the mighty wiki....

In Community health most of our patients don't know what prior diagnoses they have had, let alone what pills they take or how tall they even are, some of this is due to lack of health knowledge/literacy, or cultural implications, but this particular case, I cannot fully explain.... it went a little something like this;

me; do you have any health problems like diabetes or hypertension, or have you ever been in the hospital
patient; yes, I was in the hospital last year for that thing that killed Bernie Mac... well, you know, that "thing"
me; no, I'm not sure what killed Bernie Mac....

a few seconds later, Wikipedia offered the diagnosis; "Mac suffered from sarcoidosis, an inflammatory lung disease that produces tiny lumps of cells in the solid organs, but had said the condition was in remission in 2005. His death on August 9, 2008 was caused by complications from pneumonia"

back to the patient...

me; sarcoidosis? wow, that's pretty serious (incredulous that patient didn't know this diagnosis)
patient; no, the other one
me; (after re-re-reading the wikipedia posting) pneumonia?
patient; yeah, that one... I think

ok.. it's one thing to not know your diagnosis, yet another to define it incorrectly by a diagnosis given to a now dead celebrity.... Pneumonia, now known as the disease formerly known as that which ultimately killed (but did not chronically pose a threat to) Bernie Mac.

Wikipedia caveat; can't say it's the first time wikipedia came through as an accurate clinical resource... it's a great way to look up icd9 codes, beats any iphone ap or online coder I have found!

Tuesday, March 8, 2011

self lovin'... no not that kind

A word about self-care in medicine.... it's more than important, it's a crucial skill that they touched on for about thirty seconds of your last lecture you never attended before the final exam which you probably skipped for a pre-exam nerve calming margarita (or at least that was the plan when I was in school at a fancy shmancy institution in the warmer nether regions of the state).

the first lecture any medical provider is given should be entitled : SELF CARE; "take care of yourself, if you don't.... you will burn out and won't be able to heal the masses... let alone yourself."

ways to make this a reality?

EAT YOUR GREENS; eat well (what you eat becomes your body... is there a better reason?), bring snacks to the clinic, the kind that are high in protein and fiber, and keep a water bottle full and in reach. Watch out for caffeine (my arch nemesis, prior lover and the crack of life... yeah, we have a volitile relationship) and sugar (no siesta time available in exam room five at 2 pm) and the starchy processed junk food that drug reps and staff spread around the clinic in your most stressful and mindless moments.

WORK THAT ASS- exercise (endorphins are like legal speed... and should be fully enjoyed), plus, everyone likes to be fit and look their best. Even little bits of exercise add up to something... for example, my favorite; taking the stairs up to medical records (you will inevitably avoid facing a patient in the awkwardness of the elevator as they attempt to catch your eye and ask a question about a visit you no longer remember in any way)

 FLUORESCENT LIGHTING ISN'T JUST BAD FOR BATHING SUIT SHOPPING- get some air and sunlight ever day; take a walk during lunch, make friends with a local barrista, library or coffee shop (one of my most favorite NPs of all time used to take a walk around a mostly Mexican migrant farming town with during lunch by herself, she admitted to me one day that she like to "pretend she was out of the country" ... which I think is pure genius, and have repeated myself too many times to count. Tomorrow, I will be going to.... hmmmmm..... details pending).

TURN AND BURN- when you leave the clinic, as much as possible, LEAVE it there (it will still be there in the morning) ... this means physically, mentally, emotionally... leave it... it won't walk away. And, save your family ALL the gory details... they only THINK they want to hear them all. This is why we all need a colleague to have a drink with after work as needed (especially you women's health folks... been there.. and the conversation is less than delicious at the dinner table).
         Caveat here; huge appreciation to my friends and current partner who are always there to let me spout medical gobbeldygook after an emotional day... regardless of how much they may care about the details, a support network of people who love you is key to being a complete clinician.. and in this arena, I am blessed fully.

VOCATION vs. VACATION; ok... yes, you are an NP, a nurse, a podiatrist.. whatever. Yes, there is such a thing as identifying with a vocation.. but, it's important not to lose yourself. Limit the time you spend reading articles if you are tempted to spend every waking second on up to date at night in bed, next to your snoring partner, face illuminated by the laptop (you know you've been there, just looking up one more cause of end stage kidney disease or one more "derm quiz")... stay up on the facts, but don't overdo it... admin time at work exists for a reason, as do copious to do/to learn/to experience lists....  Take trips and vacations frequently, especially if you are lucky enough to live in a place where you can head to beach, snow, dessert, mountains, or redwood forests within a 5 hour drive (do it).

Want to heal others? keep yourself in tip top shape... not just the cerebral type... your life, and loved ones, and ultimately... patients... will be all the better for it.

Monday, March 7, 2011

the straight dope

 Although this NP takes chronic pain seriously (like one patient who was a subway attendant and was beat up on the subway landing by thugs, or another who was shot in the back in Vietnam.... and the list goes on) my office will not become the local ghetto candy shop if you know what I mean..... gotta be careful with your "rep" in these parts, because word gets out fast, and before you know it, if you could have a quarter for ever prescription with the prefix "oxy"... let's just say that I would be retiring in style....

But seriously... we have created a system where patients with legitimate pain concerns cannot access the help that they need (PT, OT, accupuncture, chiropractic.... and the list goes on) and therefore, become addicts to pain medication, and need higher and higher doses (and methadone) as their narcotic receptors quickly adjust to levels of opiates strong enough to tranquilize a charging rhino.

The secret to good practice... consistent limits which patients are well aware of... trust me, those with legitimate concerns will follow up on time, and you will soon weed out the "seekers" or "street merchants" from the "legits"....

No Narcotic refills in triage... no exceptions, same story every time.
Most of the NP triage frequent narcotic refill fliers get the picture after one or two or twelve reiterations of this same policy... but some have become extra savvy..... take mr "Smith"

me (in waiting room); Mr "Smith" I notice you are here for a refill, does that refill request contain a narcotic medication
Mr Smith; no, it's for my blood pressure
me; excellent, that is a refill I can consider, come back to the office with me and let's discuss
Mr Smith (now in office); so... I'm out of my oxycontin and my blood pressure is really high because I'm anxious
me; *shakes head, and points at door*... mr Smith, you know our policy hasn't changed, anything else I can do for you today
Mr Smith; *gets up, opens door, escorts self out of clinic.

sigh... well, at least there was no yelling or calling of security this time..... now if I can just find a way for him to make it to his follow-up appointments, that would truly be dope.

Friday, February 18, 2011

big gulp

people always ask me "what is the most disgusting or strangest thing you have seen". Ok, let's be honest, this NP has seen a TON of crazy shit in her day, and this list could go on and on.... but here is one recent "favorite" that always gets a good laugh, but seldom is shared at the dinner table....

Woman walked into triage office... obviously "tweaking"... if her nervous, jittery, face itching didn't trigger me in the first place, the HUGE cup of soda she frantically sipped through a straw would have. Walked into my office and proceeded to pull up her shirt to reveal a huge fluctuant abscess... no biggie here in NorCal, it's a regular occurrence....and we have local community wound care services that cater to just such a problem. What happened next was the true charm.....

"I have to pee"... the patient loudly proclaimed
"No problem, there is a bathroom right outside" I calmly stated.....
"No! right now!" she exclaimed as she pulled down her drawers and urinated in the middle  of my office

My office; which, I will no doubt expound upon later, is currently nothing more than a glorified janitor's closet, not more than 7x6 feet.... it's not the kind of place you want to be trapped in as a meth head does her business two inches from your iphone charger.

At this point, I had a split second to decide if I wanted to chance a urine splash my tan and blue pinstripe wool jacket and sofft heels... so I used said right heel to kick a trash can under the patient's rear as she continued to urinate in my office, when done, she pulled up her pants, thanked me for the wound clinic referral, kindly apologized, grabbed her big gulp soda, and left on her way.

A pack of clorox wipes, and a janitor visit later..... the evidence was gone.

take home message.... avoid the big gulp, or at least, always keep a trash can handy... wouldn't want to ruin a cute outfit or a good day :)

Monday, February 7, 2011

community health....NP style

Community Health.... bright eyed neophytes fresh off the graduation red carpet march into the community with ambition, ideas, and no idea just WHAT they are getting into or HOW to make it through the first day. We have all been there, and many of us struggle to keep afloat, but there are ways to bob above the current and maintain a life, and a sense of humor!   This blog will be a place to document my experience in community health over the last decade.... I have played many roles, all of them rewarding, interesting, frustrating, and ultimately, growth-giving.... posts will inspire laughter, clinical and educational tips, health care pointers, and relay stories of the never mundane world  that is the privilege of providing health care to those who need it most, and can find it no where else.