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!
Saturday, August 6, 2011
Thursday, August 4, 2011
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.
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?
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 :)
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!
"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!
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
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.
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.
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