The magical mystery land of community health

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

A Really Bad Idea March 31, 2009

Filed under: Uncategorized — lesbonurse @ 12:33 am

Scene from a new patient visit:

Me: So you’re here to follow up on a seizure that you had last month?  You were seen in the ER?

Young male patient: Yes.

Me: Is this the first time you had a seizure?

Patient: No, I had one last year.

Me: Did you see Neurology–or anyone–for that?

Patient: I went to the ER.  They told me to see neurology but I didn’t do it.  They also told me not to drive.

Me: Are you still driving?

Patient: Well, yeah.

Me: I have to tell you, that’s against the law.  And it’s dangerous.

Patient: But I love street racing.

Me: So you race?

Patient: Yep.

Me: If you had a seizure during a race, you could kill yourself.  And take other people out with you.

Patient: (shrugs)  I know.

Me: (silent scream) I would strongly advise you not to race until you see Neurology.  I would advise you not to drive at all.

Patient: Mmmhmm.

 

Another Brilliant Idea March 26, 2009

Filed under: Uncategorized — lesbonurse @ 11:42 pm

While complaining to a coworker about a disheveled, greasy, smelly man who asked me for Viagra so he could “give it to my lady,” I came up with a brilliant new idea. I am going to develop a Viagra ‘Starter Pack’. It’s going to be a cute little man-bag with a trial sized bottle of shampoo, soap, deodorant, a breath mint, a condom, lube and a couple of Viagra. Because if you’re going to give it to your lady, you need to make sure that the lady wants to get it!

 

Things not to say to your health care provider March 19, 2009

Filed under: Uncategorized — lesbonurse @ 1:21 am

These statements–all recently uttered by patients–are guaranteed to win you no points with me:

  • “Have you put on weight?  Your face looks fatter.”  (Thanks so much.  Yes, I put on weight this winter)
  • “If you don’t give me Percocet, I’m just going to go to the Emergency Room!”  (Great!  Why are you still here?)
  • “Really, I’ve been taking my blood pressure medicine every day” (Then how come your blood pressure is HIGHER on 4 different medications than it was when you were on none?)
  • “Please give me Percocet.  I won’t get addicted, I promise!” (Hmm, somehow I’m not convinced)
  • “You’re pregnant!  Wait, are you pregnant?”  (No, it’s just a flowing blouse, ok?  And yes, I put on weight!)
 

Can’t get you out of my head… March 17, 2009

Filed under: Uncategorized — lesbonurse @ 1:04 am

Today I learned about another unusual mental illness: delusional parasitosis. Also known as “delusions of parasitosis,” this disorder involves a patient’s unshakable belief that their body is infested with bugs under the skin. Why did this come up? Well, a patient who had already had a dermatology consult, a CT scan of the head and a trial of various medications came in complaining of ongoing “bugs crawling all over my skin.” Turns out he’s had quite the workup, and the only remaining diagnosis is delusional parasitosis. Of course, when you’re convinced that your body is a breeding ground for subcutaneous bugs, it’s not very comforting to hear that you’re just delusional.

You might think that this would be a rare diagnosis, but this is the 3rd patient I’ve seen in a year and a half of practice. I can’t find any prevalence data, but it seems like a high rate for a primary care practice. Is it because we have such a high rate of mental illness in our clinic population? Or maybe delusional parasitosis is a hidden plague (or infestation, if you like bad jokes)? Whatever the case, it sure sucks if you’re the person who thinks–no, knows— you have bugs in your head.

 

Oh, the horror March 12, 2009

Filed under: Uncategorized — lesbonurse @ 1:26 am

Today I had such a horrible visual experience that I can only bear to write about in in haiku form, lest I dwell on the trauma for too long:

A bladder prolapse

Like pink water balloon pokes

from the vagina

 

Standing at the gate March 11, 2009

Filed under: Uncategorized — lesbonurse @ 2:17 am

One of the big privileges–and burdens–of being a healthcare provider is being a gatekeeper. Some of it is perceived (I’m sorry, but your insurance won’t cover a full-body CT scan without a good reason–I can’t make it happen) and some of it is real (Yes, I can beg the GI department to triple-book you for an emergency appointment next week and I can probably make it happen). The concept of ‘gatekeeping’ is a pretty touchy issue in the field of transgender health. Historically, many providers have followed something called the Harry Benjamin Standards of Care . These are guidelines for gender-affirming treatment (such as hormones), but many patients and providers feel that they are too restrictive and burdensome. Some providers–such as myself–practice an “informed consent” model of care, which relies less on a standard set of criteria that is applied to every patient and more on an individualized assessment of each patient’s knowledge and understanding. Since trans health is still a new-ish subspecialty, the length and breadth of assessment can vary widely from provider to provider.

After my last trans health-related posting on this blog, I was contacted by an acquaintance of mine. As a trans man himself, he was concerned about my treatment of the teenage transgender patient. He wondered why I had doubts about initiating hormones, and what right I had to judge the patient’s gender identity. He wondered why I didn’t give the patient hormones at the first visit, and why I cared that the patient had an official letter from a gender therapist (generally, I don’t require letters, though I do appreciate at least a prior visit with a therapist). All of these are questions I asked myself as well. I drafted an email to him in response, then thought that maybe I would share my thoughts on the blog. I will admit, there is a certain amount of gatekeeping involved in many aspects of my practice. I don’t mind sharing the thoughts behind the gate.

–One of the key things to remember about my provision of hormones is that I am a nurse practitioner, not a physician. That means that I have to review and discuss my work and my treatment with a “supervising” physician. None of the supervising physicians in my office have experience with trans care, and none of them are comfortable with it. That means that if I can’t justify my treatment plans to them, I am going to have a very hard time continuing my work. This is like gatekeeping for the gatekeeper. I care about keeping my job, ergo I am very careful about how I do my work.

–I am a primary care provider, not an Endocrinologist. My job is to provide primary care for people, and I believe that hormones can be integrated into primary care. However, when someone comes to see me as a new patient, my job is to get to know them and their medical history so I can treat them as a whole person. In order to be treated by me, the patient has to have their primary care at my office. I’m not a consult provider (unlike an Endo, who may see a patient once or twice and send them back to the PCP). I can’t adequately treat any condition, including diabetes, hypertension or depression, by seeing a patient once. Therefore, hormones on demand at the first visit doesn’t work for me. That is my personal philosophy. I understand that people who feel that their gender-affirming treatment was unnecessarily delayed might disagree with this.

–Something to consider about that young person that I saw is that I prescribed hormones on the 2nd visit, which was 1 week after our first visit. I don’t consider that undue burden, nor do I consider a week to be an unreasonable time to wait while I follow up on medical records, etc. At the first visit I had discussed a treatment plan, and included in that plan that we would start hormones at the second visit and follow up in 1, 3, 6 months. I do understand that many people in the trans community have felt that they were lied to by providers who led them along and then ultimately denied them hormones. With my patients I am careful not to portray my intentions as any different than they are. And if I have a plan, I lay it out for them. At least they can see where the gates are then, eh?

 

Sunday haiku March 2, 2009

Filed under: Uncategorized — lesbonurse @ 3:40 am

Sugars not better.

Why? Using insulin pen…

but not correctly

At the gas station:

gay male porn in the trash can.

Who left this behind?

Weather predicts more

snow and freezing cold temps.  No!

Can’t take any more!

Girl with low back pain

Used mom’s fentanyl patch and–

surprise!–pain was gone

Veggies once a month:

not meeting nutritional

requirements.  Yikes!