Nurse Practitioner

Comfort Zones Part 1: The Night Shift

Posted on by writenp

When I was in my last year of NP school I volunteered at a weeklong sleepaway camp for kids living with HIV. This was in the days when “living with”  was a euphemism for “dying from.” What was I worried about going in?  Not contracting HIV.  Not even seeing kids who were very sick.  I was concerned about the night shift.

Having gone straight through nursing school to graduate school, I hadn’t worked as an RN. Many new RNs start out on the night shift. Somebody has to do it and it’s viewed as paying your dues.  In the camp program I was in, everyone was assigned one night shift, and we were partnered up so noone was alone.

Of course the night shift per se should have been the least of my worries. We were taking care of some very sick kids with j-pegs, and kangaroo feedings and weak lungs susceptible to Pneumocystis pneumonia. My nursing experience was all academic at this point. I could ace a test, but maybe not save a life.

But what I was worried about was staying awake.

In this particular program, there were mostly inner-city kids. HIV knows no demographics – anyone can contract it. But these kids were all born with it. Their only risky behavior was being born. Many of their parents had drug problems at some point. Many of the children were orphans and many whose parents were still living, were in foster care.  This I knew going in. What I did not expect was to see how happy the kids were, getting off the bus. All seemed to be excited to have a week of camp, whether they were six or 16.

The facilities were not impressive, but there was a lake for swimming, basketball courts, and plenty of room to run around. The kids stayed in cabins with a counselor, and while not fancy, accommodations were adequate. The counselors told me the kids were not used to the lack of traffic sounds and were at times frightened of the sounds of the natural world. We were not technically in the country, more like an ex-urb, but to these kids, it was very remote.

We nurses spent our shifts keeping everything stocked, treating bug bites and minor scratches, and of course, giving meds. The kids were all on a lot of meds. There were a number of ICU nurses there who easily took care of the parenteral feedings and med administration. The rest of us took care of the oral meds. The kids were stoic, having grown up taking lots of nasty-tasting stuff and swallowing large pills. They just wanted to get it over with, anxious to get back to the fun.

Our team was led by an ER doc who had done this a number of years. His mantra was to just keep all the kids well enough to continue camp. Cellulitis? Medicate and cover up to avoid transmission. Toothache? He just injected procaine as often as needed so the little boy could enjoy camp. I felt so sad that he could get this kind of a toothache at this age, but of course, he was one of the ones in and out of homeless centers without regular dental care.

My scheduled night shift was in the middle of the week. I polled the experienced nurses to see if they recommended napping that day in the afternoon. No consensus.  I tried, but it was very noisy and I wasn’t able to sleep.   Finally it was time for my 7 o’clock shift. I had coffee with my dinner but was already feeling tired. The other nurse had just gotten off the night shift at her job in a small community hospital a few months ago so she was an old hand.  We chatted. Listened to music.  Played tic tack toe.  This was in the days before smart phones.

Around 2 am we heard the crunch of footsteps on the graveled path leading to the door of our makeshift clinic. The screen door slammed as one of the male counselors came in, carrying a boy who looked about six, piggy-back style. He informed us the boy had fallen out of his bunk bed. We both knew Victor (not his real name). He was kind of like the camp mascot. He always seemed to be having fun and giggling. He had skin the color of tea with a drop of milk, blondish, nappy hair, and the sweetish smile imaginable. He melted hearts wherever he went and that was before you heard his story. Both his parents were addicts. His father had died of HIV when Victor was two. His mother had been living with the disease until last year, when she relapsed and died of a heroin overdose. Now he was in the foster care system and had had some bad placements.  You would never know it from interacting with him.

Victor looked like he had been crying but was smiling and cooperative as I examined him. His counselor told us he had not lost consciousness. He had woken from a bad dream and had been in the act of trying to climb out of bed when he fell.  Luckily, there had been s pile of rolled-up sleeping bags on the floor which had broken his fall. He had not hit his head and now he denied any pain. Nevertheless, I gave him a thorough neuro exam, checked his joints for swelling, his abdomen for possible internal injuries. Gave a good listen to his heart and lungs. His vital signs were all normal. We instructed the counselor on what warning signs to look for and they got ready to go, with Victor fully expecting — and getting — another piggy-back ride.  The other nurse told them to “hold on” as she rustled around in the bag of stuffed animals we had and gave him a large plush snake to take back to the cabin.  He was delighted.

The remaining time of our shift went rather quickly and then it was over. I had survived the night shift. My cohort and I were glad to see the day shift, chatted a bit and went to raid the camp kitchen before heading for a long nap. We had the whole day off.

Thankfully, there were no major calamities that week, but as can probably be expected, interacting with the campers was bittersweet.  Whenever I saw Victor, he was clutching the stuffed snake, seemingly none the worse for wear from his early morning fall.

On our last night, a talent show was scheduled and the kids were very into this, even taking time from swimming and games to practice. The karaoke machine was enormously popular.  The campers all seemed to know the latest music and could lip sync songs and dance like the original artists. It was impressive but heartbreaking when one of our older campers, a cachectic 16 year old girl on oxygen, gave an amazing rendition of a Selena song. The kids did enjoy the little number we nurses put together, dancing (after a fashion) and swinging our stethoscopes like feathered boas.

The next morning was a rush of packing up supplies. We had been told repeatedly at orientation not to give gifts to the kids to avoid favoritism and hurt feelings, but some nurses drove into town on their time off and did just that. I was assigned to gather up the toys to pack away for the next camp session. I went from cabin to cabin driving a golf cart and collected them. The kids had been told to deposit them in a box in their cabin. My last stop turned out to be Victor’s cabin.  As I went to drag the box out, I spotted the plush snake’s nose peeking out from beneath a bare pillow. I reached for it and Victor came running in and hugged me. “Please nurse, can’t I keep him?” he asked.

And here’s what haunts me to this day.  I said no. I explained we had to have all the toys back for the new campers next week.  Victor didn’t cry or make a fuss.  He just looked sad and nodded that he understood.  This was what I should have been worrying about instead of the night shift: how I was going to feel about those children. Was my heart already hardening out of self-preservation? I had been relying on the rules to get me through this week, a week that took me way out of my comfort zone.  Victor was dying, all the kids at that camp were.  Why was I depriving him of remaining in his comfort zone, for just a little while longer?

#patientstories, #comfortzone, #HIVcamp

Teeth Don’t Lie, or If It Walks Like a Duck…

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It was at the end of the day.  Encounters like this one always happen at the end of the day. You’re tired, your staff is tired, and you’re behind schedule. Welcome to any day of the week at 4pm at a community health center.

I had scanned my schedule as I finished my note on the last patient.  A new patient visit popped up.  A women age 43 with an unfamiliar (for this particular clinic), Nordic-sounding name.  Okay, I thought, maybe someone visiting here and not wanting to go to the emergency room. This was before there was an Urgent Care Center on almost every block. And it was always very difficult to get into a private practice for what is likely to be a one-time visit. The complaint written on the schedule was “teeth falling out.”

Oh.  Or uh-oh. Or at least, hmmmmm.  When I think of missing dentition in a relatively young person, I think homelessness/mental illness.  Or meth.  I dutifully checked Uptodate (www.uptodate.com) to see if I was missing something, like some rare auto-immune disorder. I wasn’t.

Sooo. I walked into the exam room ready for anything.  I encountered a tall, blond women, gowned and sitting on the exam table, shuffling a lot of papers.  Never a good sign. The part about the papers, I mean. I smiled and introduced myself and I asked why she was there.  Sometimes, with our bilingual front desk staff, things can get lost in translation.  For many of the staff, English is their second language and certain physical complaints can be hard to translate.  It was a hopeful thought and I decided to stick with it until I heard otherwise.

“I was at the emergency room all night,” she said, as she thrust the papers towards me.  She had a faint, Germanic-sounding accent.  In fact, she slightly resembled the model Heidi Klum. “They said I had vasculitis.”  She moved the hem of her exam robe to expose a reddish rash going down her thigh.

“Well, what did they give you?” I asked.

“It’s all there,” she responded with a touch of impatience. She tossed her blond hair, a habit from youth, I guessed, but her hair was straggly and dull,  rendering the movement ineffective.

I explained that these reports often fail to contain the information that will be most helpful to me: a diagnosis, test results and medication prescribed.  Often it is page after page of instructions and disclaimers with the important stuff hopelessly buried within, if present at all.

“They gave me this,” she said as she handed me a prescription bottle from her purse. “But I know it’s a steroid and I don’t want to take it.”

“Okay,” I said. “Have you had a bad reaction to steroids before?” It was relatively common to get palpitations, anxiety or insomnia while taking this kind of medication.

“No, it’s not that.  I just prefer to do things naturally.  I don’t like medication.  And besides, the people at the ER didn’t help me with my main problem.”

“Which is?”

“My teeth are starting to fall out.”

Here we go, I thought. “Let’s start at the beginning, is that alright? I just want get your basic medical history. I positioned the computer so I could enter the information while we still talked face-to-face.

The history she gave me was totally unremarkable.  According to her she was the picture of perfect health. She took no medication.  Her teeth just started to become loose about 4 weeks ago.  She made it a point to tell me she lived, not in the town the clinic was in, but one town over – a very upscale suburb. She also mentioned her two children who were excelling at the high school. One had just gotten into an Ivy League college, in fact.

She dug in her purse and I thought it was for her phone to show me a photo but she took out a laminated newspaper clipping with well-worm edges.  “That’s me,” she said proudly. “I was a model in my country. “

“Very nice,” I murmured. It was indeed her, about 20 years ago, and she’d been beautiful. She was handsome, as they say, even now. “Let’s get started on the exam.” I suggested.

I couldn’t really tell what the rash was, but vasculitis seemed a long shot. I thought it was a simple, uninfected contact dermatitis, which could be treated with an OTC steroid cream.  But now I went on to the part I was dreading, the oral exam.  She complained of no pain when I palpated her jaw and cheekbones. She had no swelling or bruising. I did notice her complexion was a little rough and there was one unusual scab right in front of her ear.  When she opened her mouth, it was clear she was missing a few of her back bottom molars, and when I shined a light inside, the top ones too. She wiggled a canine tooth for me like an excited kindergartener. The disconcerting sight gave me goosebumps.

“See, nurse, this is what I’m talking about.” I nodded and completed the rest of the exam. Other than her skin and teeth, nothing seemed amiss.

I excused myself and conferred with a colleague, who agreed that I had to do a tox screen.

“What’s weird is that she’s not asking for anything, no requests for opioids.” I mused.

When I went back in the exam room, I told her I was stumped. I recommended we start with some basic blood work.  I told her we needed to do a urine test as well, to test for drugs.

“But I told you, I don’t even like medication. I certainly don’t take drugs.” She made a point of holding my gaze directly, her clear blue eyes telegraphing her sincerity.

“I understand,” I responded, “But please humor me. Use of methamphetamine is a major cause of teeth falling out.  I would not be doing my job if we didn’t rule that out first “  I also wondered if they had done that at the ER.  If so, I was sure that particular tidbit would not be included in the papers she handed me.

“I will call you with the results,” I told her.

“Don’t I need a follow-up appointment?” she asked, which kind of surprised me.

“Well, you can certainly make one if you wish, but until we get the results, I’m not sure how productive it will be. We may need to refer you to a specialist.”

I went on to the next patient and my medical assistant went in to draw blood and hand her a urine specimen cup.

My last patient was an 8 year old with strep throat. Easy peasy and she was a sweetheart to boot. I was about to sit down at my desk to finish charting when my medical assistant informed me my prior patient was still here because she couldn’t pee.  She was drinking water when I entered the room. My patience was wearing a little thin. “Look,” I said, “We really need to do this test. We can’t continue to take care of you and get to the bottom of this if we don’t.” She regarded me coldly as she took the last swig from the bottle.

“Very well,” she retorted.

By the time I left that day, I had no idea if she submitted the specimen, but it turned out she had.  The next morning the urine test was back.  Positive for methamphetamines.  I called several times, leaving discreet messages asking her to call me but she didn’t.

They informed me at the front desk that she had indeed made another appointment.  She told them this time she wanted to see a doctor, “not a nurse!”, and she wanted a male doctor.  I doubted that she’d show.

I was wrong. I guess her charms were lost on me. Because the doctor, even though I had told him about the tox screen, was driven to find out what was wrong with “this poor women”.  He said she told him that she was taking her child’s Ritalin to concentrate and that’s why her tox screen was positive.

“But I asked her about medication.  She denied taking any.”

“Well, I guess she didn’t feel comfortable with you,” my colleague suggested. And  I guessed  that old modeling photo still had a certain juju.

“And she hasn’t requested any opioids?” I could not help asking.

“Oh, no,”  he responded. “She’s very anti-drug.”

It made me wonder why she came to the clinic in the first place.  Was it for the attention? Was she mentally ill?  A borderline personality disorder, maybe?  But it wasn’t my problem anymore, and there were always more patients to see.

I did ask my colleague a few months later what progress he had made in her case.

“Oh, she just stopped coming.” He admitted sheepishly, and a little regretfully.

“And her teeth?”

“Kept falling out. I referred her to a dentist but not sure if she went. She was going through a divorce and there were insurance problems and money was tight.”

I began to question myself. Maybe I was getting too hard. Could it have been really advanced periodontal disease?  Was it all from stress?  But how and why did she know the exact thing to say that would explain away her positive urine screen?

About six months later, another colleague drew my attention to an article in the local paper. “Isn’t this that women with the teeth?” It was. Her bone structure prevailed even in the mug shot.  Heidi Klum on a very bad day.  She was found sleeping in her car in that exclusive suburb.  Also found was her stash of methamphetamine.  It was sad.  I wondered if the children she told me about were real, and how they were faring in the midst of all this. I asked one of our social workers to look into it.

It continued to be a mystery to me.  Was that first visit a cry for help?  Or did she think stopping her teeth from falling out would prevent her life from falling apart?

©2017 by Eileen Healy Carlsen. All rights reserved.

To Test or Not to Test: of PSAs and Pap Smears

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The United States Task Force on Preventative Services (USTFPS) creates guidelines for providers to help them determine which preventative tests to do when, for which patients and if at all. We in community health rely on this task force perhaps more than other providers due to its global perspective. Basically their mandate is to decide, through a rigorous review of the research, whether certain tests or counseling interactions actually save lives in the long run, whether the benefits outweigh potential harm, and whether they are cost-effective. You can find out more at https://www.uspreventiveservicestaskforce.org/.

To make things more complicated, there are other specialty physician organizations with their own guidelines and the recommendations are often conflicting.  So what to do and how to decide?

If you have a good relationship with your health care provider, that is the best place to start. Discuss your risk factors for certain diseases, your age and state of health, your family history and your state of mind when it comes to medical tests and results. Personally, I am as conservative with tests as I am with prescribing medication.  There are potential downsides to every medical intervention, even tests.

Many people are surprised about this last notion.  They believe testing is good and want every test available, all for the assurance that they are healthy. But tests can have false positives – meaning they might indicate you have a condition when you don’t and thus lead to further testing or unnecessary interventions.  False negatives happen too, when the test says you’re fine but you are not.  Your provider will be able to tell you the false negative and false positive rates of most tests, as well as potential side effects, to help you make an informed decision.

An example is the PSA test, which is a blood test for a protein called prostate specific antigen, which is elevated in men with prostate cancer.  It can also be elevated in men who ride bicycles a lot, or who have an enlarged prostate, or have had a recent infection. Before 2012, we routinely tested men 50 and over, and younger men with family histories, risk factors or symptoms. If the PSA number was above a certain range, the test was repeated and if still high, they were referred to a urologist for a prostate biopsy.

Biopsies are never pleasant but prostate biopsies are particularly unpleasant given the location of the gland. Urologists try to take samples from many locations on the prostate, often guided by ultrasound or MRI, to find the cancer cells. Sometimes they do.  And sometimes they don’t.  As you can imagine, this is anxiety-provoking either way.  To compound the dilemma, many prostate cancers are very slow-growing and may not require treatment. But currently it is impossible to ascertain this definitively so depending on their age, most men are advised to, or want to, get treated.

Because of all this, in 2012 the USTFPS recommended against screening most men. A new guideline that came out just this week amended this slightly, recommending discussing screening with men aged 55-69, and then making an individualized decision.  I think that’s what most of us were doing anyway. A lot of times a man in his 50s would come in for a physical (pushed by his wife or girlfriend), and ask for the PSA test. We would discuss it and he would decide against it and with his permission, I would offer to talk with his significant other as well. Lots of times this would be a relief. The “man on a mission” did not want to go home, as it were “empty-handed,” having failed to get the test she requested.

Now on to the Pap smear, the screening test for cervical cancer. We actually call it a Pap test now because it is no longer a “smear” collected on a slide and preserved with a fixative.  It is liquid-based, collected with two tools usually: a small plastic “spatula” and a small brush. It is a better test because it requires fewer cells (so less repeat Pap tests for an inadequate sample), it can be done on days of light menstruation, and it can also be used to test for HPV, the human papilloma virus.  This is huge because HPV, a sexually-transmitted virus, is the cause of most cervical cancers, and the presence or absence of HPV in an abnormal Pap test guides our treatment and follow-up.  HPV can occur without symptoms and there is no cure or treatment for the virus itself.  Sometimes it manifests as genital warts “the HPV you can see,” and these can be treated, but eliminating the warts does not eliminate the virus.

The efficacy of this liquid test along with the ability to test for HPV is the reason behind the latest USTFPS guidelines on Pap tests: basically less is more, and later is better. This is welcome news to women, who never look forward to getting this test.

Now we don’t do Pap tests on women younger than 21, regardless of sexual activity. (We do of course test for sexually transmitted infections (STIs) and give safe-sex and contraceptive advice.)  This is because most young women have a low-risk strain of the HPV virus, which clears on its own. Before the guidelines, we were getting lots of abnormal pap smears for women under 21 which required other, more invasive tests and interventions, all of which could have been prevented by waiting. The jury is still out on how the new generation of women vaccinated against HPV will influence future guidelines.

Currently we test every 3 years from 21 until age 30. At age 30, women have the option of having the Pap test every 5 years along with an HPV test, or every 3 years without. Women older than 65 don’t need further testing if they have had regular screening in the past and do not have risk factors. This has taken a lot of getting used to, both for providers and patients. Women, as much as they dread the test, wonder if it’s okay to wait that long, is it safe? Rigorous research has proven that it is.  Some providers were still testing every year and some women wanted the assurance. As insurance companies adjusted their re-imbursement to the guidelines, this has changed. Go to this link for the particulars: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/cervical-cancer-screening?ds=1&s=cervical cancer

The bottom line though (no pun intended) is that medicine is both art and science and patients are individuals.  There is no “one-size-fits-all.”  If I have a women who wants the test even though it isn’t due yet and is not warranted clinically by the presence of symptoms or past personal or family history, we will discuss it.  Sometimes, I find out she thinks the Pap tests for all STIs and she has had a recent risky sexual encounter.  Lots to discuss including other STI testing and possibly emergency contraception in that case.  Other times there is a nebulous family history, “my great aunt died of cancer ‘down there,” or she is worried after a friend had a bad diagnosis.  As a provider, I value my patients’ mental health as much as the physical.  In some cases, I will do the test to ease anxiety, after discussing cost in case her insurance won’t pay.

The takeaway message to this rather long post is that medical tests are complicated, imperfect, at times invaluable tools to maintaining good health.  Team up with your provider to get informed, be conservative and make sure you understand what you are getting into.

Healthy Thoughts: What This Blog is All About

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There are a lot of health-related blogs out there, so what makes this one different?  Imagine if you will that you have a close relative or friend who is a nurse practitioner.  You would probably feel free to ask her or him anything about your current state of health as a matter of course. Off the cuff, spur of the moment,  things you might not ask your doctor because of embarrassment or time constraints or fear of seeming silly.

My patients often tell me nurse practitioners are easy to talk to because they listen. And I do make it a point to give my full attention when a patient is describing symptoms or as we say in the biz – complaints. That word may have a negative connotation outside of health care but it’s a simple way to describe what brought you in to see a health care provider.

Even nurse practitioners have restricted time-slots (alas!) so there are questions that you might not get to ask during an office visit. Unless you have a relative or friend who’s an NP. Then you can send emails to that person with the subject line “eye” or “kidney” or “weird symptoms.” And you will get answers.

Now before you get the wrong idea – this blog is not going to be a forum for your specific health questions.  Rather, I will discuss all the kinds of questions patients, relatives, friends, and yes, even strangers, have asked me about their health. Chances are, some of these topics will speak to you personally.  I will share with you my health practices — what I do to stay healthy, what I advise my family to do, as well as share my thoughts about health care today, including how to utilize the system to optimize your health. My goal is to improve health through knowledge, from a nurse practitioner’s perspective.

But that is not my only motivation.  The URL for the website is www.mynursepractitionerwrites.com because, well. I was a writer before I was a nurse practitioner.  And sometimes, certain patient encounters resonate with me, becoming almost lyrical in the truths they reveal about both the patient and provider. It happens when the humanity of each person comes through despite the trappings, time constraints and mechanisms of modern-day healthcare.  It’s the reason  I renamed my site, “Tales From the Clinic.”  Some of the content is clinical, for sure, and some of it reflects the meaning I find in patient stories.

Please take a look at the menu bar to find content that interests you, and if you find it helpful, or just fun to read, please subscribe to my blog at the bottom of the menu drop-down. Thank you.

© 2016-2020 Eileen Healy Carlsen, FNP-BC (board certified nurse practitioner in Family Health)

Painful Encounters, Part 2

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“Foot pain” was the reason listed for the appointment. A new patient, male, age 31. I had now been in the clinic long enough to prepare myself mentally for just about anything. A year ago a young women with the same complaint, also a new patient, had presented with an infected foot wound open to the bone emitting an odor so strong, that when she took off her shoe it made the medical assistant have to leave the room in a hurry. Turned out she had spina bifida, and got this often. Her decreased lack of sensation and frequent hospitalizations made her blasé. As we waited for the ambulance, I asked “Why didn’t you just go to the ER?” “I didn’t think it was that bad, and I don’t have my insurance yet.” She was later transported to a trauma center where she remained on IV antibiotics for 3 weeks.

The man was tall and thin with longish straight brown hair. He was wearing a gray tank top and jeans and the prison tattoo on his upper arm was displayed for all to see.  I took that as a conversation starter and made a guess. “Were you recently incarcerated?” It was a universal term, no matter a person’s first language or education level.

“Yes, got out two days ago.” I suppressed the urge to ask what he had been in for.

“Have you had a TB and HIV test?” I asked. It was pretty standard.

“Yeah, all that, I was negative.”

“We can test you again 6 weeks from now to be sure.”

“Yeah, okay whatever, but that’s not why I’m here.”

“So tell me,” I encouraged.

“Five years ago, I was working as a roofer and fell off a roof. Broke both my feet. Was in casts, the whole deal.” He grimaced at the memory. “But the docs said I needed surgery to really repair things and I didn’t have insurance.”

“Are you in pain?”

“All the time. That’s why I’m here.”

Now was the time to ask about why he had been in jail.

He looked sheepish. “Um, narcotics, a little dealing. It was all because of my foot, though.”

I was surprised at his honesty.

“Let’s do an exam first and then we’ll talk.”

He was meek as a lamb.

The exam was pretty normal. The soles of his feet were painful to the touch but there was nothing really to see. He had full range of motion, good pulses.

I took a complete family history and got ready to order some blood tests. “Oh, no, doc, I hate needles,” said the man with the crude prison tattoo.

We compromised. A urine test this time, including a tox screen and a return in two weeks for blood work and a complete physical exam. I gave him a prescription for high dose naproxen for his pain, with the appropriate caveats.

Surprisingly, he came back and became a model patient. He said he was not using and his tox screen was negative. He was depressed, not surprisingly, and I started treating that with medication. We were helping him with insurance so that he could see a specialist for his foot pain. I continued to write him scripts for the naproxen since he was having no ill effects and his labs were normal. This was during the early days of electronic prescribing and not all pharmacies were equipped for this. He told me his wasn’t and I gave him paper scripts.

Six months went by. The clinic was always swamped so it took me a while to realize he was coming less frequently. I placed a call to ask him to come in to monitor his depression meds. Left a message but no response. Next time I called, the phone was not in service. I sent a letter to the last known address. And then forgot about him.

Until two years later, when I noticed he was on my schedule again. The complaint this time was “medication check.”

After the initial greeting, I asked where he’d been, thinking he’d moved.

He had been in jail again. This time, I asked straight out.

He seemed to wrestle with how to respond. “You’re not gonna like it,” he finally said. I was sure I wasn’t. And waited.

“Prescription tampering. Well, not really, but those scripts you wrote for that medication—“

“The naproxen?”

He nodded, and added “And the other.”

“The medication for depression?” I thought I couldn’t be surprised anymore but I was. Shocked actually.

“But wouldn’t I have been notified?”

“Well, there were drugs in the car, they cared more about that. And I was never able to use any of the doctored-up prescriptions – guess my forgery skills weren’t up to par. And the way you wrote them made it hard.“ He chuckled a bit until he noticed my stony-faced expression.

“So what brings you here today?” I finally managed a neutral tone.

“Well this time, I do want help to see the bone doctor. What I told you about my feet – that was true. And um — nurse?” (patients always struggled as to what to call me.)

“Yes.”

“I’m sorry. I know you really tried to help me and I took advantage and screwed up.”

What do you say to that? I just nodded and began the exam.

 

Painful Encounters, Part 1

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I just completed the new mandated continuing education for prescribers on controlled substances in New York State. It’s part of a nationwide effort to stem the opioid abuse problem in this country, which is growing exponentially. The program was very well executed with many suggestions on how to prevent opioid abuse while still treating a patient’s chronic pain. There was also information on state-specific guidelines on prescribing, many of which have become more stringent in light of the opioid epidemic. A month ago, I also completed a similar program for the state of Massachusetts where I also hold a license, and this was through Massachusetts General Hospital. This presentation featured re-enactments of typical patient encounters. They brought back some painful memories.

It was probably my second week at the community health center. A new patient (in this particular scenario it’s always a new patient), a clean-cut while male in his late 20’s, sat on the exam table. I had noticed that he had walked in stiffly past my office door, lagging behind the medical assistant and holding the small of his back. He was with his girlfriend. He said he was visiting from Florida and his back was acting up. He had been in an MVA (car accident) 5 years ago which “broke my back” and resulted in excruciating back pain which came and went. His girlfriend held an envelope which contained an xray film. His last name was written on the corner with marker. He was disappointed when I informed him we didn’t have a light table to read the xray.

His vital signs and reflexes were normal. His lower back appeared normal without bruising or redness or swelling, but was hypersensitive to the touch. He denied fever or urinary symptoms which could signal a kidney infection. He denied loss of bowel or bladder function – a red flag which would indicate an emergent condition called cauda equina syndrome, requiring quick surgical intervention. He denied prior use of IV drugs which would make him more susceptible to a bone infection called osteomyelitis.

He did say that the pain radiated down both legs suggesting sciatica. Every motion I instructed him to do hurt – bending forward, backward, twisting. Any manipulation of his leg while he was supine was painful. Even pushing down on his head while he was sitting was painful.

He said surgery was suggested for his condition, described as “many herniated discs” but he didn’t have insurance. His doctor in Florida gave him Vicodin – the generic didn’t work. Yes he tried physical therapy but it made the condition worse. He was extremely polite and kept calling me “ma’am.”

I held up my hand and began my spiel about how opioids were not the most effective drugs for pain management. I talked about how NSAID/acetaminophen in combination had more efficacy. Suggested we start such a regimen in addition to a muscle relaxant for 5 nights. I talked about alternative therapies such as heating packs or topical lidocaine. I encouraged him to speak with our advocate to start the process of acquiring insurance so that he could get his problem re-evaluated by orthopedics and perhaps start physical therapy again. I spoke about referral to a pain management doctor if all else failed.

He listened politely and then asked, “So you can’t give me any Vicodin?” I told him I was not comfortable doing that. “Well they told me you could help me when I made the appointment.” His voice started getting louder. His girlfriend started to look anxious. “Let’s get out of here, baby” she whispered. She was too thin.

“I’m not f-ing paying for this appointment.” He continued, almost shouting. “I wanted to see a real doctor.”

“They told you I was a nurse practitioner when you made the appointment. Do you still want your prescription for the muscle relaxant? If so, which pharmacy?” I kept my tone level and neutral.

He reluctantly named one and I sent it off. I got up and said I would bring back the instructions for taking the ibuprofen and acetaminophen in rotation and a referral to our patient advocate.

When I returned to the exam room a few minutes later, it was empty. The exam table paper appeared to give one last rustle in the abandoned room, like tumbleweed. 30 minutes spent on a visit allotted 15 and I still had to write the note.