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Posts Tagged ‘New grad NP’


Monday in a rural health clinic is, well, interesting. As in the old Chinese curse “May you live in interesting times”. I am sitting in my little office cubby at the back of the building tackling the teetering pile of charts that have messages or lab and test results to be read, when I hear a panicked voice yelling “We need you NOW!”. Dashing out, I am directed to the waiting area where a young man is laying on the floor and the other patients who were waiting to be seen are backing out the door, wide-eyed.

The man was unconscious, not responding and his breath whistled whheep, whheeeep, wheeep, like a kid with epiglotitis. Oh, crap, he probably has something lodged in his throat. I turn him around to check his airway, and check his mouth and he coughs a little, mucous tinged with blood dribbles out. I put him back on his side. Panicked staff crowd around, “What do we do?” one yelled. “Call 911, get me oxygen and the ambubag!” I replied.

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He is still not responding, though the wheeping is slowing down a little, and suddenly stops. “Shit, he stoppped breathing!”, I have a sinking feeling in my chest, this guy is going to die on me. I grab him by the shoulders and shake him. “Don’t you DARE stop breathing!” I yell into his ear. He suddenly gasps a little, with a more normal sound, and starts to come round, his eyes open. He whispers “Anxiety attack”. The 911 crew arrives, just as he is starting to sit up. They ask the story and I tell them what happened. At the mention of the words “anxiety attack”, their interest cools considerably. A staff member hands me the patient’s chart, as they now know who it is. He has esophageal ulcers, asthma and GERD listed in his problem list. I pass this information along to the now bored EMTs. I mention they might want to check his lungs as possibly he may have aspirated some stomach acid, they say “thanks, sure” and out they go.

Two days later, the guy shows up for an office visit with his mom. She thanks me profusely for saving his life. When I asked him what precipitated his anxiety attack, he said “Nothing. I was just driving along and started coughing, I couldn’t catch my breath and then the panic started.” I see on his med list he is supposed to be taking Advair for asthma, and Nexium for acid reflux and the esophageal ulcers. He admits to not taking his medicine, that he didn’t feel it was necessary. I explained that a combination of refluxed stomach acid and bronchial spasms from the asthma had probably led to his coughing and panic attack. His mother gave him the stink-eye and said “I TOLD you to take your medicines!” The guy sheepishly promised to take all of his meds in the future.

Later, a guy walks in with a hospital gown on over his jeans and a hard neck brace on his neck. He hands me a pile of papers which are hospital records from an ED visit last night. The records show he has a transverse C4 fracture, nondisplaced. The story of how he got the broken neck was colorful and included beer, motorcycles and police officers and a total lack of memory about how it happened. There were multiple scrapes, bruises and marks on him, one of which looked like a boot print. Quite a night.

“I was supposed to see a spinal surgeon today,” he tells me. “But, the one I was told to see doesn’t take Medicaid. He said I had to get a referral from my primary.” That would be us. The nearest spinal surgeon that accepts Medicaid is at Shands, which is over an hour away. The patient would have to drive himself. When our scheduler called Shands, they told us they would call back to set an appointment after noon tomorrow. Our scheduler “suggested” that she would fax the referral and the pertinent information from the hospital records now and she would call them first thing in the morning to see what time the patient should show up tomorrow. We’ll see how well that goes. I pointedly reminded him to keep the brace on and not try to turn his head until seen by the spine doctor.

The sad part is, if the hospital had admitted him, he could have been seen by the local spine surgeon in the hospital, had his surgery and it would have been covered by Medicaid.

What is wrong with this picture?

 

 

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Sorry I haven’t blogged for a while. I had to make a trip to Europe as my mother as very ill, and did pass away. In a way it is a relief as she had been ill and in pain for quite a while. She is at rest now. My family and I have to deal with international laws about wills and estates, which has taken up a lot of time and energy. Mom wasn’t quite as organized as we would have liked.

Back at home, I am still loving my new job. I get to see all the basic day-to-day health issues. Last week was allergy and sinuses week, seasoned with occasional bronchitis. This week was thrush and cerumen impaction week. There also has been an increasing stream of PAPs, the ladies are catching on to the fact that there is a female provider in the house now. I did request, rather strongly, that I wanted to have the clear plastic speculums (specula?)and not the ancient metal ones I found in the drawer. They complied, thankfully. It is hard enough to peer down a vagina and locate a cervix with the lamp over your shoulder, without also having to deal with old-fashioned metal speculums. This IS a rural health clinic, but I have to draw the line somewhere. 🙂

It is great getting positive feedback. The assistants and the PA and physician all keep telling what wonderful things the patients are saying about me. Someone get a pin, my head is getting bigger. This afternoon, a patient was dropping off his Hemoccult cards (he refused a colonoscopy even though he has a history of polyps), and the nursing assistant said he didn’t look too good. The patient agreed to come back and let me have a look at him. When I walked into the room, he told me “My wife thinks you walk on water.” Well, that is tough to live up to, and I remarked that I hoped I wouldn’t fall off that pedestal, to which he replied, “well you wouldn’t drown if you did.” The hemoccults came back positive x3, his labs which I had ordered the last visit showed anemia. A glance at the last two notes showed a weight loss of 8 pounds in a month, and he was complaining of some vague abdominal “twinges”. I wasn’t able to locate the site of the pain when I palpted his abdomen, but I thought I felt something, well, thick. I told him about the hemoccult tests and the anemia. He agreed to go to GI to be checked out. I told the girl p front to make sure that he got an appointment as soon as possible. I am frankly worried about him.

This afternoon, when I was getting ready to leave, the physician sat down next to me and said “Did you hear about the 85 year old woman you sent to get an ultrasound of the abdomen and pelvis because she had some tenderness and a little vaginal bleeding?” I hadn’t, she had come back while I was away. “I just wanted to let you know that she has ovarian cancer and is getting surgery soon. I am glad you caught that.” Wow.

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One of the hardest things to do when starting a new job, is to get a handle on the office politics. The difficulty level is higher when there is a large group of physicians, other mid-levels and a large assortment of assistants and office personnel. Add some new services being set up and the mix gets a bit volatile.

I have never been a real political person, so I would have had a real problem with all of this only a few years ago. After the rigors of post-graduate education, and the “Project”, it seems that I have developed some new skills in dealing with the politics, and a higher level of personal confidence. So far, things are going relatively smoothly, and I am learning who the movers and shakers are, how to keep myself in the loop, who are my allies and which people I need to be careful around.

All in all, considering the amount of people in the practice and the sheer amount of patients seen and procedures done, this three-ring circus operates quite smoothly, and I am feeling more comfortable each day in my new role. We are settling into our new community, making new friends and enjoying the outdoor activities and beautiful surroundings we have here. There is a 43 mile long bicycle trail which runs past lakes, parks, and forest near by which we are enjoying each weekend. Life is good.

I need a new bicycle…

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During my first week as an NP, everything seemed difficult. The computer system was unfamiliar, the routine and forms also new and unfamiliar. I was a bit unsure of myself. The specifics of GI, a new territory, even with patients who had simple stuff like constipation, it just felt difficult.

Today, the first day of my second week, the routine is more familiar, the computer program do-able, the paperwork and forms are now not problematic. I am much more relaxed and able to interact with the patients in my normal way. I wrote my first order, woohoo! I get to see the patients first, then the physician gets my report and finishes up the plan. It is really nice when you tell the patient “I think the doctor will give you such and such drug/treatment”, and when he comes in, he says the same thing. Yes, validated! I guess I know something after all. There were a couple of times when he didn’t go in after me at all. Sweet.

Life is good. I have arrived. Still inexperienced in my new role, but I am feeling more comfortable. Everyone here is very nice, I couldn’t have found a better group of physicians to work with.

Clothing stores used to be hell, but now seem a lot more fun!

And, on a different subject, I went clothes shopping. I recently lost some weight on a low-carb diet. This is the only diet that has ever worked for me. My pants were getting a bit baggy, and besides, I deserve some new clothes. It’s been a long time! So, I go to the store and troll around looking for “professional clothes”, (and not in the “women’s” section this time) no more scrubs for me. I find some pretty tops and pants that looked good. I go to the fitting room with piles of stuff to try on, and….the best part is that I picked out some pants a size smaller than my usual, and lo and behold! They were too big, I had to go down another size! That has never happened before. And, they were long enough for a change (I am 5’9″).  For once in my life, I came home smiling with bulging bags after a clothes-shopping trip. I take all of this as a good sign. 🙂

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Friday was my last day working as an RN. My feet will be happy. I mentioned after the first day, that I would have to put the gel insoles back in my sneakers , only to find out they were already in the shoes when I took them off that evening!

 I have to say, I love being an RN, and I hope that as an ARNP, I will get even more satisfaction doing patient centered care. I also hope that I won’t have to be quite as physically active as those days in the endoscopy lab turned out to be. I had worked a couple of days a week in the lab, ostensibly to see what the tests are all about so I can better educate and reassure my future patients(although, being a good girl, I have had my colonoscopy and knew that test personally), but also because I needed the moola. I learned a lot about the people working at my new place of employment: a lot of characters, but a great team. Being a bit of a character myself, I think I will fit in just fine.

Well, my ARNP license is finally in, after obsessively checking my application status online multiple times a day, it was there. It was so cool to see my name with credentials: Nurse Practitioner after it on the license verification form. WooHoo!

The head physician gave me a packet of papers to fill in, to get priviliges at the two hospitals we work in. I applied and got my NPI number. Tomorrow we will have to knock out a NP practice/collaboration protocol as required by the state of Florida. We NPs must be well “supervised” by the all-knowledgable MD. Frankly, at this point in my fledgling career, I am glad of all the “supervision” I can get! I was given two GI books to read, Lange’s current on GI and endoscopy and a book of “secrets” in GI practice. Again, I am amazed at how much I actually know, and how little I actually know.

Last weekend, I attended a GI conference in Orlando with some of the nurses and physicians from the practice, very informative. My favorite lecture was “Interesting anorectal cases”……With pictures………Right before lunch……I can’t even imagine what the staff of the ritzy hotel must think. We lined up for a group photograph by the pool, and some wit in the nearby crowd yelled “Say colonoscopy!”.

Tomorrow will be interesting, my first day as a “big person” as the RN supervisor put it recently.

PS: I just saw that I was listed as one of the best 25 nursing blogs. Wow, I am honored!

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I have received my degree/diploma, my certification from AANP has come through. Now all I have to do is wait for the state to issue my license before I can actually start to work as an NP. Of course, there is still also the obtaining of an NPI number, which I understand is very quick, then the credentialing and practice protocol and credentialing at the hospital to do. I don’t have to worry about a DEA license, as Florida is one of the two backward states that does not allow NPs to prescribe controlled substances. This is a laugh as it is  a few unscrupulous MDs in this state that run the pill mills, not NPs.

Anyway, I got to spend a couple of days observing in the endo lab, which was fun and gave me a chance to see the procedures and get to know some of the other staff. An interesting moment when the nursing supervisor said to me, “We get a half-hour lunch, but, oh yeah, you are going to be one of the “big people”, so you can do what you want.”

Sweet.

I am looking forward to starting my new career. All of the staff and the physicians are really nice and supportive. It is all looking good.

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I passed my final exam…..only the presentation of my project is left.

I suppose I will have to change the blog title soon to “Trials and Tribulations of a New NP”. I have found a position with a group of GI physicians, this ought to be interesting! It is not easy to find a position when you are a new grad, I was lucky to get more than one offer, of which this one worked out the best.

The cool part is, I get to hang out in the cushy doctor’s lounge in the hospital between patients. 🙂 If I have time to hang out that is… Will keep you all posted.

 

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