Archive for March, 2007
I had my lovely 2 year old daughter on the phone this morning, just a few minutes before starting my clinic. She likes listening on the phone, but rarely says much, but this morning she muttered, “I want my daddy”.
OK, cancel everything…I’m on my way. If only.
The problem is, she is apparently not the only one who wants to see me. OR IS SHE…
Some days I get the Nurse Practitioners upset statement…
“I couldn’t see the Doctor, so I had to see you“
To this I have two urges… The first is to say: “Actually you don’t have to see me, F*** off and by the way I don’t really want to see you”
My second urge is to convert them. Prove that I am sooooo nice, thorough and helpful that in future they will want to come and see me.
Almost as annoying is the classic:
“I came to see you, because I didn’t want to waste the doctors time” and I have been known to mutter: “so you thought you’d waste mine instead”. (only very quietly and after the patient has left)
Some of those patients who I have converted, I wish I hadn’t.
One of my prime examples came this morning, essentially a charming old lady, suffers with sore throats on a fairly regular basis, and her GP gives her antibiotics. So several months ago, she had to come and see me, as her Dr. had no appointments.
I gave a good working over, showed her literature stating that antibiotics were only useful on bacterial infections and that sore throats are usually self limiting, etcetera, etc., etc.. Well she was upset, kept batting for antibiotics, and I stood my ground (I know its about coming to an agreement with the patient not dictating there care…BUT)
She left, unscripted, and her throat got better. Now she seems to think I’m the only clinician in the building who can tell whether or not a throat needs antibiotics. So every tickle, sniffle or ache she darkens my door way. Don’t get me wrong she’s a lovely lady. But take this as a warning. Careful who you convert to the dark arts of Nurse Practitioning.
Also I was left feeling unwanted…because I made a referral to the hospital rapid assessment chest pain clinic. HGV driver, with intermittent L sided chest pains, radiating into his arm. Hypertensive and an unhealthy life style.
The clinic saw him, did stress test and other investigations, and have arranged a management plan for him, but the letter back to the surgery advised this was an inappropriate referral as…”it came from a Nurse Practitioner”. Clinically sound and not so inappropriate that they didn’t investigate it and start a treatment plan, but not from a Doctor. Bloody charming!
I also had a letter from an ENT consultant, to me directly, thanking me for the referral and stating “If I can be of any further assistance please let me know”.
Now I know I have some Doctors reading – (albeit Dorky & anonymous ones) but you guys must know that it’s the little things us Nurse Practitioners celebrate, like a letter addressed to us. (and wine, chocolate, candle light and a good seeing to – although my preference is not to have a good seeing to by a Dr!)
Spirits are high in the surgery today…
…it’s Friday, it’s payday, and it might just be sunny too. (Once this grey pesky mist burns off).Read Full Post | Make a Comment ( 1 so far )
There it is, bulging in front of you….the words “do no harm” spring to mind. You could stick a needle/scalpel into it and squeeeeeeeze, so what is the definition of harm?
“Well your honour – my intentions were good….”
….and that is the kind of week I’m having…
Firstly a young lad grazes his knee, his concerned Mum gives it a clean and puts a plaster on it – she didn’t intend to do any harm - she didn’t know that ever single skin cell under that sticky plaster was going to blister due to a allergic reaction.
So feeling guilty she brings him in, perfectly demarcated red, blistered area exactly where the plaster was. So I reassure them and give some antihistamine, but that doesn’t stop our patient scratching it, he didn’t intend to do any harm…but it gets infected….
Back they come…OK – Fluclox for a skin infection….I didn’t mean to do any harm…
Back they come….glorious wide spread allergic rash. I assume the Erythromycin I then prescribed, has either given him so much diarrhoea that they’ve not been able to come and see me, or he is better!
Secondly a 2yr olds mum rings me, high temperature what should I do? Bring him in.
Assess the lovely little chap – No rash, chest infection. Good old amoxicillin (remember I have a reputation for being difficult to get antibiotic from – so he did need them).
Day later another phone call from mum.
“Oooh, his much better today, but he has a rash”
Does it go away when you press a glass on it?
“No, that’s alright isn’t it”
Well I can here him playing nicely and mum’s relaxed so I take a hunch its not meningitis. Bring him down.
GLORIOUS PURPURIC RASH. very well child. Urm.
Henoch-Schomlein Purpura. So send him off to hospital for bloods. Bloods all fine, hospital stop his amoxicillin.
Comes to see me the next day – guess what? His cough is worse. So who’s doing harm? Stopping antibiotics in a 2 year old with a chest infection.
So again the Erythromycin.
Next day – vomiting all night after taking Erythromycin.
So I stop and look – the Amoxicillin didn’t give him the rash – did it? Lets try our luck and try some Cefradine. No problems yet.
Some days – you can’t do right for doing wrong, and some days you do your best and other problems come along.
The final battle is therefore between the Hippocratic oath (it’s OK I’m not a Dr!!)
and the Scouts. Do your Best.
Just in case you didn’t know the next Change of Shift is out, with a lovely limerick theme!! Some people obviously have to much time on their hands – but it’s always nice to get a mention.Read Full Post | Make a Comment ( 1 so far )
Well it’s kind of been a frantic week.
A patient this morning gave me one of those – “Is it me?” moments, when you start to doubt whether you are missing something of clinical significance or just a losing the plot.
In his 20′s he turns up complaining of headaches everytime he uses his mobile phone on his left ear, it lasts only a few seconds after he hangs up.
So I ask if it happens when he uses a land line – no just his mobile.
What if he uses the R ear? – not tried that, he didn’t want the symptoms to spread.
Had he tried handsfree? No!
The brain starts to doubt 2 things.
1: my clinical knowledge of brain tumours related to mobile phone use – the evidence is weak, but it could be, what if…..
2: my patient. Is he simple a bit odd?
So I end up discussing it with the senior partner – conclusion.
Pt’s a bit odd. In the words of the senior partner:
“It hurts every time I stick my finger in my eye – should I stop doing it!”
The I see a woman with a breast lump. Makes me slighlty anxious. Post examination diagnosis
Hmm, best get on an see what delights the rest of the day brings…
I’ve recently been on a study day to improve my hormonal knowledge.
Alas they didn’t ask the classic: ”Whats a Hormone?” So I couldn’t answer: “I’m not doing that for that money!”
…here’s what I’ve learnt:
Pregnancy, Oestrogen and Women
Pregnancy Q & A & more!
Q: Should I have a baby after 35?
A: No, 35 children is enough.
Q: I’m two months pregnant now. When will my baby move?
A: With any luck, right after he finishes university.
Q: What is the most reliable method to determine a baby’s sex?
Q: My wife is five months pregnant and so moody that sometimes she’s borderline irrational.
A: So what’s your question?
Q: My childbirth instructor says it’s not pain I’ll feel during labour, but pressure. Is she right?
A: Yes, in the same way that a tornado might be called an air current.
Q: When is the best time to get an epidural? A: Right after you find out you’re pregnant.
Q: Is there any reason I have to be in the delivery room while my wife is in labour?
A: Not unless the word “divorce” means anything to you.
Q: Is there anything I should avoid while recovering from childbirth?
A: Yes, pregnancy.
Q: Do I have to have a baby shower?
A: Not if you change the baby’s nappy very quickly.
Q: Our baby was born last week. When will my wife begin to feel and act normal again?
A: When the kids are in university.
10 WAYS TO KNOW IF YOU HAVE “OESTROGEN ISSUES”
1. Everyone around you has an attitude problem.
2. You’re adding chocolate to your cheese omelette.
3. The dryer has shrunk every last pair of your jeans.
4. Your husband is suddenly agreeing to everything you say.
5. You’re using your mobile phone to dial up every car sticker that says: “How’s my driving-call 0800-”.
6. Everyone’s head looks like an invitation to batting practice.
7. Everyone seems to have just landed here from “outer space”.
8 You can’t believe they don’t make a tampon bigger than Super Plus.
9 You’re sure that everyone is scheming to drive you crazy.
10. The ibuprofen bottle is empty and you bought it yesterday..
This is quite bizarre, and a little bit legendary in my neck of the woods, so I was slightly reserved against sharing it as it may give away my alter ego identity, (but I’m not too worried).
Are you sitting comfortably? Then I shall begin…
It was a couple of years ago, when I was a fresh faced NP student. My next patient on the computer screen was listed with the PC of “bleeding tummy button”. The patient was an adult female, so my usual guesstimate of what I’m going to see was limited, some kind of grossly ruptured hernia perhaps???
As the patient entered my room, it was apparent that she was more than a few kilos over weight. She gave a history that she had noticed a small amount of dried blood near her belly button, but was otherwise asymptomatic.
So we took a look, she popped onto the couch and there was a tiny amount of red goo on her skin, nothing gross. At this point I should have said:
“Oh, probably just a scratch, go home and return if you have any further problems”
But no, not I – this phenomenon needed further investigation, (prompted partially by a slight malodour coming from the deep dark depths of her umbilical region)
So first I try a separate the skin as much as possible, and with the light beaming behind me, have a look. There I see something! I get a cotton bud and delve further into the cavern before me and with a nice scoop action remove the foreign body….
One dead moth….
So my patient is embarrassed, but goes away happy in the knowledge there is no surgical emergency, but from that day to this I have one question…
Surely it didn’t fly in there, so did it go in as a Caterpillar?
The moral of the story - never forget the importance of good umbilical hygiene.
Kim’s been busy again with another:
but make sure you take your tissues, the first few links are real weapy, nursey stuff (You’ve been warned)
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Sometimes getting a history is a challenge. Take this morning for example, I was (to my own down fall) distracted by the urine sample I was presented with when the patient came into my room. If I had looked closer in his notes and been less distracted it would have saved me a lot of time.
The elderly chap with the sample, tells a woeful story of sleepless nights, getting up hourly to pee. The sample is clear, so we start talking about Prostate troubles. He seem interested, taking it all in, and mentions that he has had a TURP in the past. So only then do I slip off the gloves and look to the computer. There is his repeat prescription for Flavoxate for his urinary frequency, so I mention this to him.
“Oh” he declares “am I supposed to be taking them?”
Other times getting a history is easy, but why are you telling me this? Yesterday for example…
“How can I help?”
And so it begins….
“I had a blood transfusion in 1973…”
(and the history stops)
“Well I came up in a big rash and they stopped the transfusion straight away”
The history stops again – ohh, it must be my turn to speak again… Hmm where is this leading? – Does she think she is still anaemic because of an incomplete transfusion 33 yrs ago? Oh my god, is the rash still there??
No really can’t think of much to say, so resort to a blunt but polite:
“So why is this concerning you today?”
and so comes the answer, but still not much clarity…
“Well, I was worried about Hepatitis”
Oh my god!
Did she have the complexion of an extra off “The Simpsons” ?
Did she drag her fatigued body in whilst clutching her right upper quadrant?
Was she bogged down by oedematous joints covered in more spider naevi than a paint baller.
Urrr – no actually.
Was she in fact completely asymptomatic?
So why did she come? What where her concerns?
It turns out that Anita Rodderick, founder of the Body Shop has Hepatitis following a transfusion in the ‘70’s
Does this mean I can expect every patient that had a transfusion in the ‘70’s to attend this week?
Now if only Anita had worked more on a business that “does what it says on the tin”
“Hi, could I have a fair trade liver replacement please, and those boobs are on offer so that’d be great too thanks”
Anyhow can I expect similar attendances?
Men who drove car’s in the 1950’s expecting to die in a car accident, because James Dean did?
Or drove around in the 1960’s expecting to get shot, because JFK did?
Or people who have been hit on the head by an apple going on to develop Bipolar disorder, because Sir Isaac Newton had it? (The whole apple hitting him on the head thing is a myth anyhow)
OK I’ll stop now. She had a concern and did the right thing coming to get an opinion about it. I was polite, I reassured, I did not give her my true opinion on her though, she may have been upset.
History! Let’s hope the patients can keep it to a relatively recent collection of related events. Of course my favourite is:
“I’ve had it for a while”
How long is a while?
“Oh, a good while”
“Oh, quite a while really”
Let’s try to break it down, a week, a month or a year?
“Ooooh, probably about that!”
Do you get the pain when I bang your head on my desk like this???
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So it has been a busy old week….
It started (as most weeks tend to) on Monday, when we had the Chlamydia Sexual Health Nurse Specialist, come to talk about opportunistic testing…. Apparently 1 in 10 sexually active young people have it and with its stealth symptoms, probably don’t have a clue. Good Grief…
Then there is talk on the radio about Sir Richard Branson (v.v.rich chappy, with a string of companies using the name “Virgin”) diversifying into health care, with talk around a medical bank storing umbilical cords, so that you can use your own stem cells to help with possible future illnesses…. Mucho clever.
So if the neat bearded millionaire wants to get into private health care, well why not, thought Max…..
Tick, tick, tick….
Perhaps, he should be made aware of some of the problems that exist, so that he can help out….
Tick, tick, tick…. (you know where this is going surely)
“That’s it….I’ll tell him about the Chlamydia problems and offer my services to him. Together we could open the first “Virgin Sexual Health Clinic”….
WHAT??? I think it’s a great idea. I could be the first Virgin Nurse Practitioner – surely there aren’t any others?????
So on to my afternoon clinic….TTFNRead Full Post | Make a Comment ( None so far )
I suppose my first thought goes back to a trip as a student nurse to one of the London Hospital museums. I remember lots of glass cabinets filled with kidney stones, a massive ball of hair retrieved from a womans stomach and an Alka Seltzers bottle, these are other peoples stories…
So in my working time I have removed more beads, buttons and sweets from childrens noses and tips of cotton buds from peoples ears than I would ever want to recall, however occasional something atypical makes you want to stop and think “ooooh, but why?”
As a student nurse doing paediatrics I remember a girl being admitted for what we jokingly referred to as a Dolphinectomy. Apparently she had sat on her toy wind up dolphin in the bath and had somehow managed its way past her sphincter – (likely story) Xray showed the metal of the wind up mechanism just inside her descending colon. Thankfully she managed to save herself from said Dolphinectomy by one rather painful bowel motion. (Whether or not the dolphin swam out to sea or ended up in a museum is unknown to me – hopefully it is not back in her bath!)
From the first time you hear that last breath expelled from a long time dead corpse (or the first time your departed patient PU’s on you, (how many shrouds can one dead person soil)), you realise that dealing with the dead is going to involve a coping strategy. With spirits/stiff drinks (puns intended) banned from work, you realise that your cool blue patient probably had a sense of humour, and in sharing this you find a good strategy.
As a newly qualified staff nurse in the Emergency department I was eager to please and did what the sister told me. At the start of the early shift we were keen to move the department patients to the ward. The hospital I was in had some “care of the elderly” wards outside the main building, and a team of porters in a battered old ambulance would collect and transfer them. The porters arrived to collect one gentleman. I introduced myself to the family, and dropped the back support down gentle so the stretcher poles could go under. Alas the patient stayed sitting exactly where he was, cold, blue and very much deceased. (Oooops)
The family (whom had been sitting at his bedside for several hours) turned and asked if this was normal. I asked that they stepped out while I got someone to check the old fellow over, (I may have been newly qualified but not throughly stoopid). I informed the night staff (then leaving) who had been ?caring for him, then popped an 02 mask on the patient and wheeled him round to the quiet room.
It appears that in life there is only so much small talk an elderly gentlemen can take.
A few years ago my wife returned from a night shift in a satelite community hospital. As there was no emergency department in the hospital, the doors were locked at night therefore stopping strangers from roaming in.
One of the other wards rang through to advice that tragically they had a patient die and to advise that the family were on the way, so to let them in when they rang the bell.
Sure enough, after some time had past the bell rang and my wifes colleague showed the family in to the relatives room, offered to make them a cup of tea and stated that someone would be with them shortly.
My wife informed the other ward that the family had arrived, and while preparing the body, the family enjoyed a cuppa. Eventually the ward staff went to retrieve the family, and stated that they could come through and see their father now. The family were somewhat confused by this. They had merely presented at the hospital wanting someone to treat a sprained ankle not realising that they were in fact in the wrong town, let alone the wrong hospital. Thankfully they found the whole thing quite amusing and got a free cuppa out of it. The real family turned up shortly afterwards luckily unaware of their new extended family – although had they turned up sooner it would make a more amusing tale!!!Read Full Post | Make a Comment ( None so far )
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Well…The general idea here is that I tell you a few funny stories and much more importantly anyone who happens to be passing by tells me some.
We all have those little stories that health professionals tell one another in the pub at night, it may be called “reflective practice” or “off loading“, this arena however is more for the category of “well! I didn’t know where to look“.
There are many such scenarios in my “professional history”. Some are simple…
…Guy comes into A&E having nail gunned his trainer to his foot…
…or the slightly more bizarre - Guy comes into A&E complaining of dysurea – and due to his slight air of oddness, I have an urge to call records and get his notes down… A fascinating large file for a 21 year old, with various artifacts the surgical team felt should be cleaned and left in the notes, for curious people like me. Cause of his dysurea turned out to be the biro he had put up his penis…. Apparently it all started when he was 14 sitting by a river and showed his mates how easy (and fun??) it was to cathetarise with fishing wire. As he got bigger so did the foreign bodies…. Hmmm probably going to need a category just for FB’s.
I am also a bit of a fool for saying things that come out either in the wrong place at the wrong time or are just too open for interpretation, so we’ll have a “Did I say that?” area.
and see where we go from there… Come on in the waters lovely…
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