The magical mystery land of community health

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

The things people say August 30, 2009

Filed under: Uncategorized — lesbonurse @ 5:24 pm

There’s always a few comments each week that make me laugh, even on the bad days.

  • English-as-second-language patient, describing her asthma symptoms: “I have weasels in my chest.  Weasels, when I breathe.  Weasels!”  (wheezes)
  • Me, to older man: “I’m pretty sure that rash on your forehead is herpes zoster, which is also called shingles.  Do you see how it has all those blisters and scabs, in a line?  That’s a sign of shingles.”  Patient: “Mmm, No.  I don’t think so.  I think it’s something else”  Me: “Do you want the medication we just talked about?  The kind that can prevent you from developing a nerve pain after the sores are gone?”  Patient: “Naw.”
  • Me, to post-menopausal patient who was worried about imminent pelvic exam: “I’m going to use a small speculum for your pap smear, ok?”  Patient: “That’s good, honey, because that factory has been closed for a long time!”
  • Schizoaffective patient, informing me that he just fired his therapist for insulting him: “Did you know that ‘knee-jerk’ means ‘asshole’?”  Me: “Actually, I’ve never heard that before.”  Patient: “Yeah, I didn’t know that either, but that’s what she called me and then I found out she was calling me an asshole.”
  • Me: “Do you think you could be pregnant?”  Patient: “If I am, somebody better call the news because it’s going to be a fucking miracle!”
  • And the ever popular sweet-drink overload.  Me: “You drink the sweet teas from McDonalds?  The 32-oz for $1 ones?  How many do you drink a day?”  Patient: “Three”  Me: “That’s 96 oz of sweetened beverage a day.  I think this is contributing to your weight gain.”  Patient, looking crestfallen and disappointed: “Ohhhh.  Really?”
 

Battling Burnout, Part 2 August 25, 2009

Filed under: Uncategorized — lesbonurse @ 3:25 am

I was just settling down to write this post when my gf stepped on a nail in the basement while working on a project involving saws and boards (and boards with nails sticking out). There was a small flurry of excitement involving wound irrigation, tetanus-shot record-finding and online checking of indications for repeat Td booster shots. After this chance to showcase my nurse-y skills, the dust has settled and the gf is ok (and is up to date on her tetanus booster).

So it’s been a month since I initially wrote about feeling like I was racing towards burnout. I realized that I had to make some changes if I wanted to stay in my job without become a bitter, grumpy beast. Since then, I’ve been trying to make better choices with my long-term mental and physical health in mind. These are the things I’ve done:

  • I changed my schedule to work 1 evening a week, which allows me to have a morning off to go to the gym, run errands, drink coffee on the couch, etc.
  • I took advantage of my employee health benefits–which I think of as the “Please Take Advantage of This Fitness Program So You Don’t Get A Chronic Illness And Cost Your Insurance A Million Dollars” program–and hired a nutritionist at a discounted rate. I was instructed to cut down on carbs and sugar, increase my protein and increase my exercise. Could’ve seen that one coming, I guess, but it’s been helpful to have guidance from a professional. Somehow the nutrition talks just aren’t as motivating when I give them to myself.
  • I’ve been focusing on making my electronic notes shorter without sacrificing too much quality. It’s an ongoing struggle between my need for brevity and my tendency towards wordiness. Some of my notes now take only 5 minutes to write, but others still take 20 minutes–especially the complicated ones that involve a lot of chart reviewing. Sigh.
  • I’ve been going back to the gym with the goal of exercising at least 3 times a week. I’ve gone back to yoga a few times, too.
  • My wonderful collaborating physician who co-signs all the charts for my transgender patients arranged a meeting with the agency’s grant-writer to discuss getting some grant $$ for LGBTQ health and outreach. It’s a dream at this point, but it’s an awesome dream!
  • I’m in therapy. Can’t deal with shit from work and family drama at the same time without professional help.
  • And most difficult, I’ve been trying to let go of my desire to be liked by everyone I work with. I’m not trying to be a bitch on purpose, but there are some things that are meant to be delegated and there’s no way to make everyone happy when I’m trying to lay out some new boundaries and expectations. It sucks to go from “I’m your friend-colleague, not your superior!” to “Fax this form for me, please” but it has to be done.

Still on my list of burnout-avoidance projects: start a “gratitude journal,” exercise daily instead of 3 times a week, go to bed by 10p.m. So far I’m feeling good, though.

 

Sunday night haiku August 17, 2009

Filed under: Uncategorized — lesbonurse @ 12:45 am

Summertime still here.

How do I know?  “Bug bite with

new cellulitis”

Scourge of the city:

Bedbugs.  Can’t kill the damn things!

Find new apartment.

Diet counseling

for gout.  Who eats organ meats

anyway?  So gross.

 

Gross medical fact of the day August 12, 2009

Filed under: Uncategorized — lesbonurse @ 1:24 am

Fungal sinusitis can sometimes develop into a condition known as “fungus balls” in which a ball of–yep, you guessed it–fungus develops in the sinus cavity. Eeew.

 

Who’s to blame? August 11, 2009

Filed under: Uncategorized — lesbonurse @ 1:14 pm

Recently, the New York Times online published an article titled “Are Patients in Part to Blame When Doctors Miss the Diagnosis?”  The article discusses a problem they dub “process of care lapses,” which is essentially a slowing of the diagnostic process.  This ‘slowing’ can be due to a provider mistake (such as an inadequate exam) or a patient error (such as missing an important diagnostic test).  The article then asks how much responsibility the provider bears for illnesses that result from these process of care lapses.

It’s a good question.  If I’ve learned one thing from working in a community clinic, it’s that I can’t make the patients do anything.  I’ve also learned that managing follow up in a clinic with thousands of patients is really challenging, and not very efficient.  Here’s an example: a woman in her 60’s goes for her routine mammogram, and they find a small mass.  She gets a phone call about the results and is advised to go in for repeat views.  She does, and they confirm the size of the mass.  She is called again and scheduled for a stereotactic core biopsy  She misses the core biopsy appointment due to a family emergency, and does not reschedule.  Four months go by, during which she does not come to the clinic because she is not due for any routine health care.  She returns to the clinic for a blood pressure check, and to the horror of the doctor seeing her, we realize that she never had the core biopsy of her breast mass.  We scramble to reschedule the biopsy, calling the patient incessantly to make sure she goes.  It’s cancer.  We scramble to get her into the oncologist.  The patient’s HTN is uncontrolled.  We scramble to squeeze her in for urgent visits, tinkering with her BP meds in the week leading up to her lumpectomy.  She finally gets the lumpectomy 6 months after the original mammogram, and is currently undergoing treatment for breast cancer.

What happened?  Who do we point the finger at?  The patient, for no-showing an important diagnostic test and failing to call to reschedule?  The PCP, for not looking up the core biopsy results and finding that the patient had never gone?  The clinic, for not having some kind of flagging system that would have alerted us to the missed appointment?  All of the above?  In this case, I think having a system in place that would flag the PCP about the no-show would have been most helpful.  The PCP could have called the patient, who–while needing some encouragement–was willing to get the test done.

But how about this patient: A woman in her 40’s.  A single parent with inadequately treated bipolar disorder.  Insulin-dependent type 2 diabetes.  Her HgbA1c is consistently >10.  She rarely gets her medication refills when she runs out.  She has a very hard time motivating herself to use her insulin on a daily basis.  I see her a lot when she has a problem, like her recurrent cellulitis.  I never see her when the cellulitis has healed.  I have sent letters asking her to come to the clinic.  I have visited her in the hospital to remind her to come see me for her post-hospital-discharge appointment.  She never came.  She never called for refills.  Busy with other patients, I stopped trying to get her to come in.  I didn’t see her for a few months.  Then last week, I got a letter from a local surgeon.  My patient–a woman in her 40’s with Type 2 diabetes–just had her first amputation.  Sad.  Is anyone to blame?  Me, for not calling the patient again?  The patient, for not taking care of her own health?  The local mental health facilities, for not having the resources to hold her hand and make sure she shows for psychiatry appointments, and then for not being with her in her home to give her the medications?

I think “blame” is a harsh word to use.  We all have some responsibility when patient’s illnesses are missed or poorly managed.  This includes the patients, who do have the responsibility to call us when they miss an appointment, or to let us know when they run out of medication refills.  But the providers, as the most health-system-savvy of the bunch, have the responsibility to make the system as easy to navigate as possible.  So now that I’ve identified the problems, I’ll get right on that health-care system overhaul.  Should be easy, right?  ha.

 

I can tell we have a lot of work to do August 3, 2009

Filed under: Uncategorized — lesbonurse @ 1:21 am

Me, looking at office glucometer: So your blood sugar is 395.

Patient: Oh. I think it’s probably high because I’ve been stressed a lot.

Me: Last time it was 400.

Patient: Yeah. I don’t know why! I barely eat anything at all. Why does this happen to me?

Me: Tell me what you had to eat today.

Patient: Nothing! Only water!

Me: Really? It’s 4 p.m. Aren’t you hungry?

Patient: Well, I had some coffee this morning. With some crackers.

Me: Ok. Well, the crackers could make your blood sugar go up a little bit.

Patient: Oh yeah, I also went to Taco Bell with my daughter. But don’t worry! I had something with chicken in it.

Me: Like a burrito? A taco?

Patient: I don’t know. But it had chicken. Chicken is healthy, right?

Me: Well, it depends what’s…

Patient, interrupting: Oh, I forgot! Then I went to Wendy’s with my nephew.

Me: You went to Taco Bell and then to Wendy’s?

Patient: Yes, but don’t worry. I only got a shake!

Me: A shake has a lot of sugar in it. A LOT.

Patient: It wasn’t the biggest size.

Me: How often do you eat at Taco Bell and Wendy’s?

Patient: Oh, not that much. I usually eat at better places, like the Olive Garden.

Me: Do you eat the breadsticks?

Patient: I get a salad.

Me: Do you get the pasta?

Patient: Sometimes. But also the salad!

Me, weeping a little inside: Have you ever seen our nutritionist? She could really help you figure out which things to order when you go out to eat.

Patient: I don’t think I need to see her.

Me: Everyone can use a little reminding about how to eat a healthy diet. I think it might be good for you to see her a few times.

Patient: Ok, I’ll go.

Me, conscious of the fact that we have vastly exceeded our visit time already on discussion of a different issue: Great! I’m doing the referral right now. Take this up to the front desk. I’ll see you in 2 weeks. Bring your glucometer, ok?

It is a huge bummer to know that this patient needs about 10 hours of intensive diet and diabetes education, and I can provide less than 20 minutes of that. And the 20 minutes also included a discussion of leg pain, psychosocial stressors and a skin infection.  Sigh.