The magical mystery land of community health

I don't make this stuff up!…but I do change identifying information.

A Higher Standard October 6, 2011

Filed under: Uncategorized — lesbonurse @ 2:04 am

The new WPATH (World Health Association for Transgender Health) Standards of Care were released while I was at the recent WPATH conference.  It’s definitely a move in the right direction!  You can read the new standards here.

The conference was interesting.  For the first time, I felt like I was legit to identify as a “real” transgender health provider in front of some of the big names in transgender health.  On that note, I will finally get my ass in gear to write down a few of the interesting or challenging problems in trans health management that I’ve come across:

  • Pelvic pain in FTMs: This is a widely reported problem among FTMs (or at least, among those on the Eastern Seaboard).  Why?  No one really knows.  What I do know is that at least half of my trans guys who are on testosterone report mild, moderate or severe crampy pelvic pain.  Most patients report that it feels similar to menstrual cramping, although they are not getting periods anymore.  For some patients, it’s associated with sex or orgasm.  The workups that I’ve done (ultrasounds, and in 1 case an endometrial biopsy) have been negative.  NSAIDs are somewhat helpful, but don’t seem to completely take the pain away.  Hysterectomy is reportedly the only definitive treatment; in my patients who have succesfully gotten  a hysto for pelvic pain (n=2), they reported that they still get twinges of pain but that the more severe cramping is gone.  Other than recommend a heating pad, ibuprofen and a surgical consult, it seems that there isn’t much to be done for this problem.  I have changed my informed consent counseling to include discussion of this problem before initiating testosterone.  No one has decided not to go on T because of it, but I think it’s important that people at least know that it might (probably will) happen.
  • Estrogen levels that don’t go up into normal female range on the recommended dose: When I first started to see trans patients for hormones, I was extremely careful to follow the existing protocols from other clinics, in terms of dosages and labs.  I’ve had a couple of patients whose estrogen levels just did not rise into the moderate-normal reference range, despite being on spironolactone and/or finasteride.  I increased the dose of estrogen incrementally, and in some cases it took a high dose to achieve the desired effects.  I have one patient (who is  >300 lbs) on 10mg estradiol IM every 2 weeks, which is twice the recommended dose.  (As an aside, I rarely use IM estradiol unless the patient has a good reason to want/need it, since it’s no longer a recommended mode of delivery).  I have another couple of patients who are on 6mg estradiol daily, which is at the top of the usual recommended dosages.  I don’t feel like I’m going crazy with the estrogen…there are just some cases that require more.  I’ve tried to be open-minded but careful when increasing people’s doses.  So far I haven’t had anyone with a major adverse event.  *fingers crossed*
  • Persistent vaginal bleeding in FTMs on testosterone: Most patients will become amenorrheic within 6 months of an adequate dose of testosterone. However, I’ve had 1 patient who has continued to have regular menstrual bleeding every month for almost a year.  I had another patient who resumed monthly bleeding after a few years of amenorrhea (he’s one of the people who got a hysto).  Both of these patients had testosterone in the normal male range, and the one who never stopped having cycles has had testosterone above the male range for several months (we’re in the process of adjusting the dose to lower the level).  We’ve tried going from every 2 week injections to weekly injections, without improvement.  Why does this happen?  Is the testosterone aromatizing to estrogen and then keeping the female cycle going?  Are the patients’ bodies just resistant to the cycle-suppressing effects of testosterone?  I don’t know.  The solution, in both the cases, was Danazol.  It’s a very effective medication at suppressing menstrual bleeding.  However, it doesn’t really answer the question of why.  For one of the cases, the hysterectomy has cured the problem.  For the other patient, a pelvic ultrasound is pending.  After that, we’ll probably pursue a surgical consult.
 

A Bitter End September 13, 2011

Filed under: Uncategorized — lesbonurse @ 12:39 am

The end is not for me, but for one of my patients.  A homeless alcoholic, “Jason” came to see me in intermittent bursts.  I could tell when he was on a bender because I wouldn’t see him for a few months, and then I would see him once a week for a few weeks in a row.  He’d come back to the clinic ready to enter detox, pledging to take care of his health, take his meds, give up drinking.  He’d do well for a little while, but eventually he would slide back into the streets and start using his SSDI for alcohol instead of medication.  Despite his drinking and his anger management problems (which could usually be defused by a few jokes and a smile), I liked him.  Over the past 6 months, I saw Jason going downhill.  A few times he asked to be sent to detox, only to be turned away for lack of beds.  He started talking about wanting to kill himself, and he started making suicidal and self-harming gestures.  He was seen at the ER on multiple occasions, drunk and cutting himself.  Each time, he was evaluated by the local crisis team and deemed safe to release once he sobered up.  Once he was evaluated by the crisis team in the morning, cleared for release and seen by me in the clinic 4 hours later, threatening to kill himself.  We talked him into going back to the ER to try again for a psych bed.  He did go back to the hospital…only to have the crisis team refuse to evaluate him because he “has already been evaluated today.”  It was really disheartening to watch, because I knew that he wasn’t a guy who was just looking for attention.  He was a guy who was really, seriously depressed and had no resources or support.  And our sad little city didn’t have enough resources to help him, either.

Today I got a call from the medical examiner.  Jason was found dead a few days ago.  It looks like a suicide.  I’m not surprised.  I am sad, to know that this was the culmination of months of struggling, asking for help and being turned away.  This wasn’t a guy who was pretending to be happy until the day he killed himself.  This was a guy who was asking–sometimes begging–for help.  We just didn’t have the resources to save him.

 

Where it started August 19, 2011

Filed under: Uncategorized — lesbonurse @ 2:28 am

I owe some thanks to the commenter who noted that I don’t actually have to write down all of my trans health thoughts in the same post.  Yes, it seems obvious…now.  I have a tendency to panic a little in the face of large tasks, though.

I’ve been wanting to write a post about how I got started seeing transgender patients.  I’ve talked to several health care providers who have expressed interest in integrating transgender care into their practices, but don’t know how.  I’ve also talked to providers who don’t particularly want to do trans-specific care (ie: hormones) but would like to learn more about how to be a trans-friendly provider.  A lot of people that I talk to want to know why, as a non-trans person, I wanted to get involved in trans health in the first place.  The simple answer is: because trans people are my friends and loved ones, and my community, and I want them to have good health care.  The longer, more academic answer is that if you look at the data about health care access, transgender patients face many barriers to care.  I find it unacceptable that someone would be turned away from care–or discouraged from seeking care–based on their gender identity or expression.  If you want even longer answers, let me know and I can send you some journal articles about health care access and the effects of discrimination on trans people.

I had an advantage going into my training as a nurse practitioner, because I already knew that I wanted to provide LGBTQ folks with healthcare.  Aside from a class about cultural competency that included LGBTQ info, I did not receive any extra training about transgender health.  BUT…I was motivated to learn on my own, and I had professors who were supportive of that.  I did class projects that focused on transgender health care, I brought trans speakers to the school to discuss general info and health care protocols, I worked with the administration on their non-discrimination statement (to include gender identity) and I integrated transgender health into my thesis project.  At the end of all of that, I was at least as qualified to talk about trans health as any doctor coming out of medical school.

When it came time to look for a job, I decided not to look at any LGBTQ-focused health centers.  My larger passion is for working with underserved populations, and I wasn’t actually very interested in working with middle or upper class gays.  I decided to go for a community health center job and see what I could do with the queer health stuff once I got settled there.  I was lucky–really lucky–to end up in a clinic with a very awesome, feminist, lesbian-identified doctor on the staff.  She has done amazing things at our clinic, and she is a staunch advocate for nurse practitioner autonomy.  After a few months of working there, I told her about my thesis topic (trans health) and that I was interested in LGBTQ healthcare.  She was excited and introduced me to one of the only local therapists who sees queer/trans patients within our community (most trans-identified people in our area have to drive 30-40 min to see a therapist who has trans-experience).

The therapist and I met to talk about our experiences and our practice philosophies.  She was excited to have someone to refer patients to who wasn’t 1) 30+ minutes away 2) an endocrinologist who follows the WPATH Standards of Care and 3) was familiar with the community.  Once I started getting referrals from the therapist, I got nervous.  I was excited about the chance to prescribe hormones for people in a way that I thought it should be done, but I was scared to do it alone.  At that point, I had been in practice for a little under a year…long enough to stop freaking out about every patient, but not long enough to feel confident doing new things alone.  Especially when the new thing is often viewed as a specialty best left to endocrinologists (not MY opinion, btw, but a common opinion among primary care providers).

I knew I had to seek out support, both to help me be a good provider, and to cover my ass in case the doctors at my clinic found out what I was doing and started freaking out.  I joined a trans medicine email list.  I started going to more LGBTQ medical conferences.  I read through other clinics’ protocols for care.  I talked to my doctor-ally about what I was doing, and she agreed to support me.  She still co-signs every one of my charts, and I like it like that.  She respects my autonomy and judgement, but I know that the medical world is full of people who won’t treat my decisions as valid without a MD signature at the end.  And this is an area in which I really do want to cover my ass as much as possible.  Sad but true.

So that’s where it all began.  Now, 4 years later, I feel much more comfortable with all the curveballs that I’ve been thrown since those early days, but that’s a story for another day….

 

The Totally Inappropriate Comment August 9, 2011

Filed under: Uncategorized — lesbonurse @ 2:08 am

I’m still working up to the trans health post…I want it to be good, which will take time, which is a stumbling block to the actual writing of the post.  For now I’ll just write a quickie.

  • Patient: “I just moved in with my new girlfriend!” Me: “That’s great.  How long have you been together?”  Patient: “A week. She’s really nice.  I just wish she didn’t have so many problems.  She has a little ‘habit,’ so I’m helping her out with some money.”  Actual comment: “Well, no offense, but maybe you should be careful where you put your valuables while you’re getting to know her better.”  Totally Inappropriate Comment: “Look, I know that you’re old and lonely and kinda crazy and unwashed, and that this girl is putting out in exchange for the money and a place to stay…but seriously, this is not going to end well for you.”
  • Patient: “I need a brain specialist, someone who can tell me about what’s wrong with my brain.  A specialist.  For my brain.”  Me: “Didn’t I refer you to a Neurologist a couple of months ago?  That’s a brain specialist.”  Patient: “No, but I need someone to talk about my brain.”  Actual comment: “Yes, that’s what a neurologist does.  It’s their specialty.”  Totally Inappropriate Comment: “Yes, you do need a brain specialist.  But I’m not sure what they can do for you at this point.”
  • Patient: “I have a cough, and phlegm, and weasels in my chest.”  Actual comment: “Wheezes in your chest?”  Totally Inappropriate Comment: “Weasels?  Bwahahahaha!”
 

Slip of the tongue August 3, 2011

Filed under: Uncategorized — lesbonurse @ 3:20 am

We all make stupid comments sometimes.  Yesterday’s mistake, said to the mother of a tiny newborn baby: “So, how old was he when he was born?”  D’oh.  I meant “how much did he weigh when he was born?”

My favorite slip of the tongue–by far–wasn’t made by me (I swear!).  One of my old co-workers, a heterosexual women’s health NP, had her hands on a patient’s vagina and said “Ok, now I’m just going to take a lick.  A look.  I meant a look.  Oh my god.”  I laughed for days about that.

 

 

A little love for the Medicaid patients July 18, 2011

Filed under: Uncategorized — lesbonurse @ 1:51 am

Thanks for the comments on the previous post!  I’m going to write this one first, and then hopefully a longer, trans-health focused post next.

As I’ve made clear in almost all of my posts, I work in a community clinic.  90% of our patients are covered by Medicaid, Medicare or are uninsured.  I’m pretty sure that my transgender patients make up a good chunk of that remaining 10% with private insurance.  Ha, kidding–sorta.  Most of our privately insured patients are those who live in the area but are lucky enough to have found full-time, gainful employment with one of the few large local employers.  A few are my transgender patients who commute in to see me.

Unlike a lot of blogs I’ve read, I don’t mind taking care of Medicaid patients.  In fact, I love my patients.  Here are some reasons why:

  • First and foremost, my patients are survivors.  Yes, they may have poor coping skills. Yes, some of them may try to solve their problems with violence.  But my patients are scrappy, streetwise and tenacious, and I love that about them.  If I had been raised alongside my patients, I have no doubt that I would also have some maladaptive coping skills, but I can only hope that I would have as much sass and will to survive.
  • Every so often, I get to see some truly awesome fashion.  One of my patients recently came in for an appointment in a tight tank top that read, in huge letters, “ONE CLASSY BITCH.”  I was like, yeah, you own it!
  • Even if I wanted to, I couldn’t sell out to the pharmaceutical companies.  Most of my patients’ plans will only cover generic/older treatments, and I have to go through an enormously burdensome authorization process to get newer/more expensive drugs.  When a patient really needs something that’s not covered, it’s a pisser.  But 9 times out of 10, we can manage their illness using a cheaper drug.  So…in your face, fancy packaging and every-so-slightly different “new” drugs!  You get no money out of me.
  • Because most of my patients have limited computer access, I very rarely have to deal with someone who comes in with a print-out from Dr Google, asking me for expensive tests to diagnose something that they read about online.  The majority of my patients are not entitled in the same way that wealthier patients can be.  Yes, my patients demand “a scan” for their tension headaches.  Yes, they want “a blood test to make sure that I don’t have cancer.”  And occasionally they’ll ask me  to “test me for everything, like every possible disease.  Like cancer and stuff.”  But you know what that means?  It’s a chance for me to do a little health education.  It’s not an unpleasant exchange where someone questions my competence or demands to see a supervisor.  Please note that I’m not saying that all upper class patients are assholes–just that they can be difficult in a whole other way.
  • The majority of my patients have behavioral health issues.  Mostly this is garden-variety depression and PTSD, but sometimes it is schizophrenia, or bipolar, or some undiagnosed kind of crazy.  This can be really challenging to work with, but it’s also pretty rewarding.  I like it when I can come up with interventions that are tailored to people’s particular needs.  It also means that if I spent half of my visit providing supportive listening, I’m actually doing an important intervention.  So many of my patient’s feel unheard and unwanted that my 20 minutes of undivided attention can make a big difference.  (documentation tip: “Supportive listening” is what I use in notes instead of saying “Didn’t really do much but listen to the patient talk about their problems for 15 minutes”)
This isn’t an exhaustive list, but it’ll have to do for now…I’ve got to get back to the Mom thing for a bit. :)
 

A question for you, readers: July 8, 2011

Filed under: Uncategorized — lesbonurse @ 2:04 am

Despite my lack of regular posts, I do frequently think about things I’d like to write about in this blog.  In an attempt to motivate myself to write + see what people want to read about, please give me some feedback.  Of the following list of topics, which would you most like to read about in the next post?

  • A look back at the experiences of 4 years of community health practice
  • A look back at 3+ years of being a trans health provider (I now have almost 50 patients!) and discussion of interesting cases/situations
  • Funny patient stories
  • Discussion about a recent trend in young, lesbian women in my community choosing to get pregnant
  • A post about the things I really enjoy about working with my underserved population (seems like people always post rants about working with poor/medicaid patients, and I think it’s time they got some love)
 

 
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