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Archive for the ‘Nursing and Health’ Category


One thing I have learned is that the presenting complaint is never what you think it is.

Foot pain: An elderly lady came in complaining of foot pain. She had told the nurse it was bothering her a lot and wanted to know what to do about it. On examination there appreared to be a crusty area between the last two toes of one of her feet. She points out “It was pretty swollen up for a while”. I try to gently clean away some of the crusty stuff and just see a little bit of a macerated area. I questioned her if she had a podiatrist as she was diabetic and she said she did.

 “He operated on that toe a while back, and the nurse came and dressed it and they took out the stitches last week”. Okay……..Well, I advised her if it was still sore she should check with the podiatrist. She agreed that was a good idea, she denied any other issues when I asked if there was anything else she wanted to talk about.

I left to give my report to my preceptor, the good doctor….he agreed the patient should return to the podiatrist to have it checked.

We go back in the room. “So,” he says, ” I hear you are having some trouble with your foot, but that you are going to get the podiatrist who operated on it to check it out.”

“That’s right”, she says, “But that’s not why I came in today, I wanted to talk about my cough.”

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Before I write my post, I have to express my sadness at the horrors that the people of Japan are facing. My prayers go out to them. No other words would be adequate…

Okay, my post about student nutrition. Every day I dutifully educate and counsel patients on diet and exercise to reduce weight, cholesterol levels and blood sugar. I feel like such a hypocrite.

 When the long clinical day is over, and I flop down on the sofa, the last thing I feel like doing is planning and cooking a nutritious meal, or riding my bicycle. I still have to spend at least an hour or so inputting the patient encounters into my log on the computer, respond to the weekly case study and look up and review some of the things I saw that day. By the time that is done, the brain and body are catatonic. My husband is not in any better shape. While he was unemployed for quite a long while, he was an angel, taking over the cooking and shopping. Now that he has a job, he is exhausted when he gets home. The job he has is very physical, and being in his late 50’s, it is tough on him.

Bottom line, at dinner time, we look at each other blankly, wishing that a cook would miraculously appear to feed us. So, in general this is the nursing student dinner hit parade:

  • Pizza: the guy at the local pizza shop recognizes Randy’s voice now and can take our order before we even say what we want. It is always the same, thinking up new and exciting pizza combinations is beyond our mental capacities. I suspect our house is programmed into the delivery guy’s GPS as a favorite.
  • Chinese food: again, the guy recognizes us, and also knows our order by heart
  • Omelet: It takes exactly 7.5 minutes to make an omelet with cheese and toast
  • Grilled cheese and soup: This takes about 13 minutes, so we need to be more ambitious for this one.
  • Healthy Choice or Kashi box dinners: These come in when we are feeling guilty about too much crap food and the clothes aren’t fitting so well.  One or two nights of this has us back on the phone ordering pizza.
  • Fast food: I can say we are proud of ourselves in that we almost never eat fast food, partly because it is so disgustingly bad for us and partly because we have to drive pretty far to get it.
  • Publix hoagie: If I have even a tiny bit of energy on the way home, I will sometimes stop and pick up a large Italian hoagie which we share.
  • Rotisserie chicken and macaroni and cheese: otherwise known as death by cholesterol and salt. Now this is not the boxed macaroni and cheese, that is WAY too much trouble, I mean the dish of nice, creamy frozen mac that you heat up in the oven. We can make this combo last a couple of days. If we are really ambitious, there will be a salad with this.

Here is hoping that we survive the nutritional deficits until I graduate. Then, I will have the time and energy to enjoy cooking again. My cookbooks and cooking magazines will get dusted off, and the kitchen will smell of baking and spices again. I will have to see if I can locate my bicycle under all the stuff in the garage.

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It’s time to collaborate— not compete—with NPs

It is time—time to abandon our damagingly divisive, politically Pyrrhic, and ultimately unsustainable struggle with advanced practice nurses (APNs). I urge my fellow family physicians to accept—actually, to embrace—a full partnership with APNs.

Why do I call for such a fundamental change in policy?

First, because it’s the reality. In 16 states, nurse practitioners already practice independently. And in many more states, there is a clear indication that both the public and politicians favor further erosion of barriers to independent nursing practice. Indeed, such independence is outlined in “The Future of Nursing: Leading Change, Advancing Health,” published by the Institute of Medicine (IOM) in October 2010. Among the IOM’s conclusions:

 • Nurses should practice to the full extent of their education and training.

• Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.

 • Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.

Second, I believe our arguments against such a shift in policy don’t hold up. Despite the endless arguments about outcomes, training, and patient preferences, I honestly believe that most nursing professionals—just like most physicians—practice within the bounds of their experience and training. Indeed, the arguments family physicians make against APNs sound suspiciously like specialists’ arguments against us. (Surely, the gastroenterologists assert, their greater experience and expertise should favor colonoscopy privileges only for physicians within their specialty, not for lowly primary care practitioners.) Rather than repeating the cycle of oppression that we in family medicine battle as the oppressed, let’s celebrate diff erences in practice, explore opportunities for collaboration, and develop diverse models of care.

 Third, I call for a fundamental shift in policy because I fear that, from a political perspective, we have much to lose by continuing to do battle on this front. Fighting fractures our support and reduces our eff ectiveness with our legislative, business, and consumer advocates.

Finally, I’m convinced that joining forces with APNs to develop innovative models of team care will lead to the best health outcomes. In a world of accountable health care organizations, health innovation zones, and medical “neighborhoods,” we gain far more from collaboration than from competition. As we ring in the new year, let’s stop clinging to the past—and redirect our energies toward envisionin g the future of health care.

From an editorial by Jeff Susman, MD. Editor-in-Chief of the Journal of Family Practice

Here is a link to the article: It’s time to collaborate

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Just a quick post.

Between the rashes and blood pressure med refills today, I think I saved a life.

One of the nurses grabbed me and said “I need you right now”, and took me into one of the exam rooms. The patient was sitting on the end of the exam table, crying, literally wringing her hands and then pulling her hair. It turns out she was so depressed after losing two family members to illness and having severe financial problems, she no longer wanted to live. She had a plan.

Her husband had brought her in because she was so distraught. He thought upping her antidepressant would do the trick. I could see in her eyes and body language that upping the med was not going to do the trick. She hadn’t told him about the plan.

After talking with her for a while, I convinced her to go into the hospital to be stabilized. She gave me a big hug and a little smile as they were taking her to the ambulance with the crisis worker. I hope she will be okay, but at least she won’t die today, hopefully she will be able to come out of it and be able to cope with her troubles. I’ll pray for her.

It was a good day.

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I have now spent four days clinical time at the health department. I like my new preceptor, she is patient and receptive to questions. I tend to ask a lot of questions…

I have seen a lot of patients and am finding that they seem to belong to three groups in general.

1. Those who have no insurance or are on Medicaid, and find that the health department primary care clinic is a reasonable option for basic health care needs. The amount billed is based on financial need on a scale ranging from full pay to free care. It is a pleasure to help them meet their health care needs, I know what it is like not to have insurance, so I can relate. These people are happy to get the care and tend to follow the treatment plan set up for them.

2. The walking train wrecks. These are people who wait until the latest possible moment to seek health care for a problem they have, or they wait until they have several problems, and try to pile them all into one visit. For example it might go something like this: I have had a runny nose and cough for three weeks and now it hurts to breathe, and I have this really big pimple on my butt that just keeps getting bigger, and I ran out of blood pressure medications 2 weeks ago and my back hurts really bad.

3. The yes, buts. These are people who come in very regularly claiming to feel lousy (and they most probably do feel lousy) and want you to fix them up, or maybe really not. This is what I mean…

Okay Mrs. Smith, I see you are here for your diabetes and blood pressure check. Did you bring your sugar readings log?

“I would’ve, but I forgot. They have been much better, in the low 100’s.

Mrs. Smith, that can’t be quite right, your A1c reading is 11.3  which is higher than last time. This reading indicates that your average blood sugar is in the high 200’s, not the 100’s.

Yes, but that was because of the holidays, it really has been lower most of the time.

I really need you to bring in your log next time, okay. Have you been following your diet?

Yes, but it is too hard to follow and I really like to eat, so I don’t always.

Are you walking 30 minutes at least three or four times a week? Remember how important it is to exercise?

Yes, but  a lot of days I forget, or it is too hot out.

You know it is very important to take your blood pressure medication every day as prescribed, are you taking your meds? Your blood pressure is quite high today.

Yes, but I don’t like the water pill. It makes me go to the bathroom too much, and I didn’t get my refills yet, so I ran out yesterday. Do you have any free samples? I just forget to take them sometimes.

Did you get the medication box we discussed that you can fill each week so you can remember to take your meds?

Yes, but I forget to fill it up. Oh, and my feet are swelling up really bad, can you do something about that? I am feeling so tired lately, and I gained 6 pounds last week. Is there a pill I can take to lose weight?

 

I swear, some people just like to complain, and if I hear “yes, but”  one more time, I may scream. Well, maybe not, but I’ll roll my eyes when they aren’t looking.


 

 

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So, Christmas is done, the presents opened, Christmas dinner consumed, friends and family visited and partied with. Only New Year is left and then back to clinicals. My dogs have enjoyed the extra treats, opened their presents, removed squeekers from the stuffed ferret, though the hedgehog still has its grunter intact. They still look longingly at the tree, hoping for more goodies.

There is more....isn't there?

 

I am quietly sitting in my favorite chair, working on an appliqued quilt block. The Fitzgerald study book is laying on the table, causing little rushes of guilt about not studying. I am going to be seeing a whole new type of patient (adults) and am getting the usual feeling of “oh crap, I don’t know anything” again.  After the last rotation in pediatrics, though, it is a little less. It is nice to realize that there is still some room in the old brain to acquire knowledge and experience, and that after an initial period of insecurity, things will look up. I am told that my new preceptor loves to teach, so I am looking forward to a rewarding experience.

There are only eight months left until I graduate. I am hoping to get a couple of trips in after graduation and before I start a new job. My family is in Europe, and one of my best friends, so a trip to Denmark and Holland is planned, and I would also like to see some friends in Pennsylvania and a friend in New England who has a puppy from one of my dogs.

I can actually believe I will be getting a life again. And a career that isn’t a disease (hopefully). Being an RN has been a wonderful thing, but health care going the way it is, the jobs were getting tough to do. Too much paperwork, not enough respect or time to be with patients and actually do nursing. When I graduated nursing school, RNs still made beds, bathed and fed patients. There was an enormous amount of clinical information you could gather from those simple tasks, which I felt were vital to doing a good assessment on your patients. I feel sorry for RNs now, who are responsible to assess their patients with information obtained from “patient care technicians” with a few weeks training, or a quick run in and out of a room to pass meds. That is scary to me. I hope that this trend reverses, for the sake of the patients and the overstressed nurses trying to care for them. I hope that hospitals and nursing homes realize that the heart of their service is nursing, and treat the nurses with the respect they are due and allow them to do their jobs by giving them reasonable workloads and time to do their jobs properly.

Hopefully, being an NP will be different, with some of the same paperwork headaches, but with more responsibility, challenge and patient care focus. I am looking forward to a happy and rewarding career with the opportunity to use my nursing skills to the fullest. I don’t plan to retire until I physically can’t do the job anymore, and hopefully that will be at 99 years old.

Now, I just need to get through the next eight months, and pass my certification exam…

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In light of all the political garbage recently purporting to save American healthcare, I propose that we have the power to save ourselves. Being only partially employed while I go to school, I have no employer backed health insurance, and even when I did, the insurance was still expensive and left a lot to be desired. It started me thinking.

Health insurance should be like other types of insurance, it only covers the disasters. Does your car insurance cover oil changes and windshield wiper fluid? Would you want to pay a higher premium to cover those types of expenses? I would think not. Does your homeowner’s insurance pay for cleaning supplies and new lightbulbs? Of course not. So why do we expect health insurance to cover the little dribs and drabs of regular healthcare?

I have bought insurance through one of the major companies with a $1000 copay, and coverage for hospitalization, and emergency room care that involves a procedure like splinting or admission to the hospital. It costs me about $133 dollars a month, though I am sure that is going to go up when the health care “reform” starts to take effect. I did however, have similar coverage before with another company and when they raised the rate to $180 per month, I switched. Granted, I have no major health problems, even at my age of fifty+. However, I do take care of my health, I don’t smoke, try to maintain my weight at a reasonable amount, and don’t use any chemical substances as happiness substitutes (Alcohol included. My consumption of a glass of wine at a holiday dinner constitutes my drinking).

So, people I talk to say, “Oh my goodness, how terrible, you don’t have access to regular healthcare!”.  What CRAP that is! Of course I do. It’s called patient managed healthcare, or PMH. This is how it works.

I wake up one morning and I have a pain in my right side, bad pain. It doesn’t go away for a couple of days. Okay, this needs to be taken care of. I call my family doctor’s office. Note: I did NOT go to the emergency room. Emergency rooms are for emergencies, like gushing arterial bleeding, heart attacks, strokes, knife sticking out of your back. Stuff like that. Not diarrhea, the flu, a pimple on your butt, a cut on your finger, or a headache. Getting back to the story. I call my family doctor’s office, make an appointment for later in the day.

Some people will say, I don’t have a family doctor, or my doctor would never get me in the same day. This is where the PMH comes in. Several years ago, when I first moved here, I asked around for a recommended MD in the area. I went to the one suggested, tried him for a while, didn’t like him, fired him. Next, I asked nurses where I worked for a recommended doctor. (Nurses are the best ones to ask…) A couple of names came up. I called the offices of those doctors and asked to interview the doctor before I signed on with them, one refused, the other agreed. This doctor let me come in that day over his lunch break to talk. Definitely a good sign..we talked for quite a while, negotiated our health care agreement and Bingo, I had a family doctor. The negotiations included the fact that I am a bit stubborn, like to do things a certain way (as few drugs as possible for example, and I like vitamins, etc.) and am not the type to blindly follow directions. He, bless his heart, was good with that and agreed to discuss options with me for every problem, and let me do it my way if it was within his parameters of feasible care, and we would switch to his way if mine didn’t work. I LOVE this doctor. Over the years, I have stopped arguing with him and I trust him now completely. I pay him a reasonable fee for a visit depending on the length of the visit, usually around $50-60. He also has open scheduling so that there is always an opening if I am ill and need to be seen that day. All good.

So, I go to my appointment, he listens to my presenting complaint and history of current illness. A physical exam follows. The differential diagnosis includes the possibility of a kidney stone. The normal route for a kidney stone is a urinalysis, a CBC and a CT scan. The urinalysis is done in the office. The CBC is important since it will tell us if there is an infection somewhere, so that is a must.

The CT scan is expensive, but in the negotiation, we decide the CT can wait, the CBC can’t. The urinalysis did not show blood, which decreased the chance of the kidney stone, but does not rule it out. I went to the lab across the way and got the CBC, it cost me $23.85.  I went home with a strainer and some samples of a med to help the ureters relax to help pass the stone. If the stone didn’t pass, or the pain got worse, then we would have to do the CT scan.

Luckily, the pain passed, and if the stone did, it was very small and I didn’t catch it. The total cost for this illness, including the lab, was around $125. If it had been done the usual way, it would have been thousands in ER costs, CTs, etc. Since I was in charge of it all in partnership with my own physician who knows me, the cost was minimal.

The bottom line: each individual should have a HSA where they put, say, 1-2% of their income from day one, have insurance only for catastrophies, and have a family physician or family nurse practitioner that they have a good working relationship with, and a sense of responsibility for their own health and health care. The price of medical care would drop like a stone. If labs, hospitals and imaging places knew everyone was shopping around and paying CASH, good old capitalism and market influences would do their magic. The other bonus is the large reduction in costs for the physicians, with the massive reduction in paperwork.

Oh, and get the fricken lawyers out of healthcare: TORT REFORM. Please! I know that this isn’t the total answer, but it would be a starting point. Some other people are getting the same idea though, see  http://www.faircaremd.com/about_us    http://www.patmosemergiclinic.com/     

There just has to be a better answer than the monstrosity the government is trying to foist on us. My mother just moved back to Europe, the model of socialized medicine we are supposed to emulate, and told me she could not get her colonoscopy or other screening tests there because “they don’t do those screenings for people over 70 years old. They save that kind of stuff for the younger people, because there isn’t enough money.” My mom is over 70, what happens if she gets sick? I shudder to think.

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