Writing

Consumption

Posted on by writenp

I find the magnitude of consumption of health care frightening, and I’m a health care provider. I’m not talking about preventative care, which I think, if anything, more people should consume.  And of course people must seek care for sickness and trauma. I am referring to medical testing and specialty care.

Medical tests such as blood work and imaging studies (x-rays, MRIs, CT scans, and ultrasounds) are overconsumed. Most health care providers, in their personal lives, are quite prudent about their own consumption of medicine in general.  We know that every test has a downside and we want to be sure the information it will provide overcomes the potential risks.

Many people, particularly those with very good insurance, think when it comes to testing, more is better. I understand that some people really want assurance that there is nothing wrong. My Spanish-speaking patients frequently ask me — “favor de chequear todo” — to test for everything – including all cancers, to get a clean bill of health.  Of course that is not possible.

Another type of excess consumption occurs when patients want to consult a specialist for the most minor of complaints, ones that could easily and safely (not to mention more economically) be taken care of by their primary care provider. Specialists are a great resource but if one sees a myriad of specialists more than your primary care provider, sometimes health care suffers. It is very possible no one is stepping back to take a holistic approach to you as a whole person, not just a foot or a heart or a GI tract.  Patients don’t always tell their PCP which specialists they’ve been to and specialists don’t always send a report, especially if the patient has not provided a PCP because they don’t need a referral.  Contrary to popular belief, providers don’t all know each other and records don’t magically get sent to your provider’s office. This is especially problematic when medicines are prescribed and there is not a complete list which would make checking for potential interactions possible.  You as the patient need to be pro-active about this, for your own good health.

While it is true referrals are a pain for all concerned, the concept of a gate-keeper for your health, i.e., the PCP, is a good one. Yes, insurance companies use the referral mandate as a way to cut costs, but the upside is that your PCP knows what is going on with your health. We can help you determine which kind of specialist to see, if warranted. Often this is not as clear-cut as one would imagine.  So even if you don’t need a referral, you might want to talk to or message us about what is going on and why you think you need to see a particular specialist.

That being said, there are some medical offerings I wish my patients would consume more of.  Screening colonoscopies and flu shots come to mind.  I sometimes have to have to push very hard for both.  Hope you got your flu shot this year – it’s still not too late. While it’s true it’s not as effective at preventing the flu as it’s been in past years, the efficacy is still around 30%.  Way better than nothing.  Plus the flu shot mitigates the severity of influenza if you are unlucky enough to still catch it.  I was very grateful for even this level of protection when I was taking care of patients with influenza last week.

Stay healthy, and be mindful of your medical consumption.

©2018 by Eileen Healy Carlsen, FNP-BC.  All rights reserved

Living Like A Dog

Posted on by writenp

The expression, dying like a dog, has a negative connotation.  Not sure it should.  It evokes the image of some poor canine smashed by a car and taking its last whimpering breath alone on the side of the road.  We’ve had many dogs, and when it was necessary, facilitated good deaths for them: a special meal, a comfortable bed, petting and paw-holding as the needle went in. But this post isn’t about dying like a dog, it’s about living like one, especially in the face of medical uncertainty.

Dogs don’t even try to make sense of the universe. Maybe that’s why they sleep so well. They wake up each morning with high hopes, tail-waggingly ecstatic just to be alive and with their family to start a new day. They like their routines and have certain expectations, sure. Something good happened once, maybe it will happen again. Like breakfast kibbles. Or that bird who flew into a window and landed stunned at the bottom of the outside basement stairwell. Our three dogs checked that space for months afterward for another gift from heaven. (Don’t worry. We rescued the bird before it came to any harm but it was exciting for the dogs, just the same.)

Dogs are optimistic but they are not without their fears, and that doesn’t just pertain to rescue dogs. The gate fell on one of our dogs once. Now she will not push on it even when it’s clear to an observer that it’s just resting against the stair. Or something fell on another dog from a shelf when he was eating in this corner of the kitchen – he really can’t have a relaxing meal in that spot so the bowl gets moved.

When I admire how dogs live I am thinking of how they live in the moment and find joy in routine things – a walk, just being let out into the backyard, going for a ride in the car, finding an old toy. Each happenstance sparks pure happiness. It never gets old.  Dogs are always up and always up for anything. At least a good part of the time. Dogs get ill and dogs get injured but how they deal with these setbacks is to minimize them and try to carry on. Animal behaviorists say this is due to the pack mentality – if a pack member shows weakness, they will be left out, left behind or perhaps killed. I get that, but I wonder if there’s more.

Just as dogs naturally want to exercise their bodies, which of course, is beneficial to their health, I wonder if they naturally want to continue to enjoy life through illness and injury. To live until they die, so to speak. We had a chocolate lab once who quite suddenly lost the use of her back legs due to a spinal tumor. She valiantly attempted to walk in the yard and managed to do her business. She wasn’t in pain and when she noticed our concern looked nonchalant as if to say – what? I walk like this now. She also famously pulled herself up the stairs to the 3rd floor that same day. She refused to give in to this thing that was happening to her. Sadly, we found the tumor was malignant and the prognosis dismal, and she was euthanized.

As a health care provider, I applaud when my patients take care of themselves and value their health. However, I have friends, acquaintances, relatives and yes, patients, who I think spend too much time worrying over every symptom when they could be enjoying the day. By all means, get your symptoms checked out if they’re worrisome or you are unsure. Follow your provider’s advice in terms of treatment and surveillance. But don’t obsess about the unknown. None of us knows exactly when we are going to die, but die we all will. The thing you worried about the most, likely is not the thing that will kill you. And even if it is, what did the worrying accomplish but compromise your enjoyment of everyday life?

Live like a dog while you can. Run after the ball, savor the treat, and smile when the wind blows back your hair. Be generous with your affection and most of all, spend time with the people you love.

Hobbled: Running, Plantar Fasciitis and My Mom

Posted on by writenp

One of my earliest memories is of my mother instructing me how to propel myself on a swing to soar above the then cement-covered playgrounds of New York City. “Stick your legs out and pump!” she coached three-year-old me. I didn’t know what “pump” meant and she had no understanding of aerodynamics. It didn’t go well.

Like many runners, I did not grow up athletic. In fact, I come from a family of remarkably uncoordinated couch potatoes, particularly on my mother’s side. This did nothing to stop my mother from attempting to teach me physical skills she herself did not possess, such as the afore-mentioned swinging.

One concussion and many skinned knees later, I accepted my lack of athletic prowess. After all, I was in good company. Hardly anyone in my family knew how to swim, let alone skate, ski, or play tennis. You’d think it had to do with lack of money but my father, the lone exception, grew up poorer than anyone, yet knew how to swim and skate. He learned to swim by being thrown by his buddies into New York City’s East River. I know. Amazing he was able to procreate after swimming in that toxic soup.

According to family legend, my mother sank like a stone when thrown into a local pool as a teenager and had to be pulled out ignominiously by the seat of her raggedy bathing suit. I have to assume being thrown into a body of water was a rite of passage back then. Lacking my father’s innate abilities, my mother was unfazed, and determined that I learn how to swim.

When teaching me by the side of the local pool didn’t pan out — “Kick your legs, and alternately stroke with your arms, taking a breath every other stroke!”– my mother scrimped to send me to a day camp specifically to learn to swim. I contracted a bad case of swimmer’s ear on day one and had to sit out pool time for the remaining two weeks.

Cutting her losses, my mother set her sights next on bike riding. Quickly she realized this kind of tutelage required a degree of coordination and strength far beyond her own. This was especially true when the child in question had no sense of balance. Someone was bound to get hurt.

My father finally managed to teach me how to ride without training wheels when I was eight, a feat akin to teaching Koko the gorilla American Sign Language. Soon after, I got bumped by a car when I attempted to cross the street between two parked cars. (Hey that’s how we rolled in the Bronx.) Lacking the self-preserving reflexes possessed by most humans, I failed to put my arms out to break my fall. For weeks I sported a grotesquely fat lip and lost the tooth I hit 10 years later.

Catholic school did not help me improve my athletic skills. The backs of my legs always sported welts from misadventures in jumping rope. Jumping-in eluded me and forget about Double Dutch. The dreaded dodge ball in gym was a little bit “Lord of the Flies” in terms of lax supervision and Piggy, I mean I, knowing neither how to throw nor to dodge, was often the worse for wear.

I found my people when I left the nuns and went to a “special” public high school with a concentration in science. You had to take a test to get in and it had nothing to do with physical fitness. Our most popular team was math team. My dodge ball days were over.

In college, there were two major obstacles for the non-athletic — the dreaded swim test and a gym requirement. The swim test, though well intentioned, was a source of severe anxiety to certain demographics. Namely, the poor, the foreign and the phobic. We had not learned to swim as children and could not believe we had to do so now.

There was no choice but to take the introductory swim class. Yes, it was a bit like that rite of passage my parents endured. But at least it counted toward the mandatory gym credits. I found it was a major advantage not to be phobic and to have English as a first language. I actually learned to swim the required three strokes as well as tread water after jumping off the deep end, a feat never to be repeated.

I’m drawing a blank on how I managed the remaining college gym requirements This might have something to do with repeated head trauma sustained during introductory volleyball — I couldn’t help closing my eyes when the ball was in flight.

I know I tried to be more active during those four years. Inspired by a boyfriend at the time, I even attempted “jogging” for the first time. I barely got to half a mile before I had to sit down on the curb, out of breath and half suspecting I might be having a heart attack.

Fast forward 25 years or so. My daughter joins the cross country team her first year of high school. Inspired by a not well-received wish to show solidarity, I start to run. And I like it. I took it slow and was gratified to find that my prior life of sloth left me pristine knees and hips compared to experienced runners.

I started doing some races. Controverting popular running wisdom, I began with a very hilly 10 K and finished (that alone was my goal) in a little over an hour. The vomiting at mile 3 was just an added bonus. Running became my way to relieve stress, to think, and to keep middle age weight gain under control while still eating (and drinking) what I wanted. This past summer, I toyed with the idea of a half-marathon and upped my distances, getting to 12 miles.

I felt strong and fit. Clearly I was overconfident. Ran perhaps more than I should have one weekend with friends who were marathoners. Or maybe it was the neon Easter-egg colored minimalist shoes that didn’t give enough support but were so cute. The next time I ran, I felt this searing pain in my heel about 2 miles in that would not permit me to continue my run. I hobbled home.

Plantar fasciitis (PF). Once thought to be an inflammatory condition, currently the etiology was being debated. There was no consensus on best treatments. It depended somewhat on whether you consulted a podiatrist or sports medicine orthopedist, how far you were willing to go (injections of platelet rich plasma, anyone?), and how much you were willing to pay.

As a health care provider, I tried what the literature suggested and what I in turn had suggested to my patients. Non-steroidal anti-inflammatories and prednisone, an oral steroid, didn’t help, which gave credence to the latest thinking that PF might not be an inflammatory response to injury. I did all the proscribed stretching exercises daily. I took up yoga again. (Downward dog is the perfect stretch for plantar fasciitis.) Decided to eschew steroid injections based on my research and orthotics based on prior bad experience.

I believed the cause in my case was a sprained ankle about six weeks prior that I ran on too soon. The ankle was weak and threw off my gait. So I started cross training at the gym to build up strength. Faithfully stretched, used a foam roller and massaged my foot with a frozen rubber ball daily. Wore the snazzy Strasburg sock at night (https://www.amazon.com/strassburg-sock).  Got fitted for more supportive (albeit slightly less cute) shoes at a running store.

Almost six months later, it is definitely getting better. Some days I have no pain at all. I can run four miles outdoors, five on the treadmill with minimal discomfort. I’m back, baby.

I often wonder what my mother would have made of this newfound running obsession and my recent struggles. She wouldn’t have understood it but she would have put her two cents in. “Propel yourself forward while swinging your arms,” she might have called out, undeterred as always by her lack of personal experience. “Shorten your stride and increase your cadence. And don’t forget to stretch.”

Thanks, Mom. I think I got this.

#plantarfasciitis #RunningInjuries, #unathletic, #HobbledNoMore #RockingThatStrassburg Sock

 

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…

Posted on by writenp

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.

Healthy Thoughts: What This Blog is All About

Posted on by writenp

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

Posted on by writenp

“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

Posted on by writenp

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.