backlash?

whip lash from a car accident, this one i'm familliar with, but when you live in earthquake territory.... then a patient might just have earthquake-lash. Ok.... imagine waking up, to the jolt of an earth quake, quickly sitting up in bed, and whipping your head back and forth. May lead to a nasty cervical spasm, as it did with one kind patient I treated today!

Just wanted to post because we both got a chuckle out of the reason for her neck pain..... ice, rest, and some muscle relaxants will have her back to good in no time (some arnica homeopathic remedies will help as well!).

Q and A

this in response to NP Odyssey's comment regarding ways we can update patient information and help with visit efficiency; Thought it was a "pearl" worth posting (why do I actually hate the "clinical pearls" term, somehow it rubs me the wrong way.. but it's universally used and therefore understood... it fills in the same category with me that "midlevel provider" does)....

Here it is;

one thing that can really help [with preparing for an efficient visit] is an agenda setting form that the MA has the patient fill out prior to the visit, it can have the patient list the three things they want to address in the vist, and also ask if they have been seen in the ED/specialist (so you can get the record), gotten any labs or studies done (so you can get the result ready), and if they need any forms filled out (so they/you can get a head start)... this helps to focus the visit from the start, and helps the provider enter the room prepared (by a handy MA who read the agenda form!).... it's an amazingly simple way to help with visit efficiency and also empower MAs to their highest licensure level (part of the patient centered medical home model). Tom Bodenheimer at UCSF is doing some great research regarding similar strategies to combat the ever increasing demands of primary care; http://www.annfammed.org/content/5/5/457.full

Over the counter and in the kitchen....

Remedios Caseros... Home remedies...

- in community clinics, our clientele is rich with remedies, many helpful, many not so helpful, and some a bit comical culturally speaking.

Today, my elderly client with impetigo came in for a re check, bactroban and septra are certainly clearing up the lesions well.. but his arm was covered in a thin layer of a dried red substance...

"Sir, what did you put on your arm here" I asked
"why, tomato juice, they tell me it's good for itching"
- apart from a theoretical use for dogs sprayed by skunks, can't say I've seen this one used as a remedy before.. asked him to d/c use for now so the bactroban can penetrate well without any interference.

- That being said, a quick google search showed multiple sites including "Dr Granny" that claim that tomato and it's acidic PH can help with pruritis.

Sometimes, remedios, and our Latino communities openness to using them can come in handy, for example;
- Te de Manzanilla (Chammomile tea); good for "calming nerves" and soothing/rehydration of the sorest viral pharyngitis patient

- liquado (smoothie) good for constipation especially during pregnancy;
- yoghurt (natural low fat) ; probiotics and calcium
- a few prunes or dates; fiber, laxative action
- papaya; natural digestive enzymes
- flax seed (grind fresh); fiber, laxative, omega three action
- Nopalitos (cactus leaves); research shows that they can be good for glucose control and may help with insulin resistance.. this being said, they often aren't a full substitute for other diabetes treatments, but are worth a shot!

any other favorite remedies out there? Would love to hear about them!

worried well

I have had a week of many worried well patients coming into the clinic... post holidays there is always a rush of panic attacks, anxiety and depression as many lonely patients seek help for ongoing stress related conditions, but I can't recall a week of such interesting and random worried well complaints. This being said.. I have had a huge influx of questions... ranging from "is it ok to take vitamin C with my antibiotic" to "can you just check my blood pressure, I feel fine, but just want to know what it is".. to my favorite, "do you know of a person that would come to read to me in my house while I recover from the flu?" (Uh... no, sir, I do not.. but ask your local library... librarian is probably cursing under his/her breath at me right now). In addition, I have seen an increase in the "phantom phone call" visits.. patients receive a phone message, aren't sure from whom, or what number, but are convinced their primary care clinic might be the origin of this call, or know of the details.. i have not had ONE case where I have been able to track down any clarification of said supposed call.. nor a patient that has saved a voicemail message for me to even listen to. Sometimes I suspect that it may be an automated message from our new clinic phone system... but then a re check of a non-up-to-date phone number quickly confirms that this could not be the case.

Take home message(s);

- your doctor or NP knows a lot, but not everything...
- we appreciate the respect that your assumption that we DO know everything communicates, and are glad you feel well cared for
- save phone messages, and write down names/phone numbers.. hell, when you call us, listen to our voicemail that asks you to do the same, an kindly comply
- when you change your phone number and/or address, update the clinic please.. we need to reach you sometimes, and make sure you know your phone number as well.. especially if it has changed (and we recognize the unique life scenerios that necesitate frequent contact info changes).

that is all. Happy Friday!

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 :)

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.

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!

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...

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.

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!

Morado

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?

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 :)

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!

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!

washeteria....

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 myself...one 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.

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!);

http://www.medpagetoday.com/Neurology/ADHD-ADD/25634

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.