Journal from behind the desk…
Part of my daily battle is explaining contraceptive methods to a patient who comes in and simple says “I want to go on the pill!”
“OK dear, here we are!”…. Oh if only it was that simple.
First you have to tip toe through the mine fields of contra-indications for the various contraceptive groups: This included the medical twist on the “not tonight dear I have a headache” which is… “You have migraines…No COC for you!” If you unfamiliar with the abbreviations, all will become apparent further down!
Even if you’ve established that they may be an uncomplicated patient that can use any type of contraceptive, you then have to give the patient choices, and these have to be informed. I find I have so much information to give out and so little time in which to do it!
Ok so you’ve 10 minutes to establish any medical reasons they shouldn’t have any particular method of contraception, discuss safe sex, be satisfied they are not already pregnant having had UPSI! (I’ll give you that one now… as it is probably my favourite medical abbreviation: UPSI stands for Un-protected Sexual Intercourse. Obviously I like it because it sounds like the sort of thing a perfect gentleman would say when they realises his mistress is not “on the pill”. Oooops Daisy. I was horrified to find my daughter talking about UPSI, when she’s not even 2 yet).
If the patient has had UPSI, then you can give them a MAP!!! (that’s the Morning after pill, and not directions on where to buy cots, and absolutely nothing to do with helping men finding the “G” spot).
…and then still in 10 minutes you have to go over the following options.
COC: That’s the Combined Oral Contraceptive. Whoever decided to think that title up should be shot. What’s wrong with calling it a CCT (Combined contraceptive tablet)? It would save patients seeing it written down and saying…”If it wasn’t for COCK I wouldn’t need a contraceptive!” This “funny” gag gets reused later in this post too!
With COC’s you have to advise the patient that it can cause:
- headaches…(more “Not tonight love, I’ve a headache” gags!);
- weight gain (but not as much as an 8lb baby);
- and increased risks of thrombosis and cervical cancer, but not much.
POP: Progesterone Only Contraceptive (and not the sound of a condom allegedly breaking). Easy peasy, less risk of complication, although if you miss one by mistake there is an increased risk of getting a parasitical infection with life altering effect. The parasite slowly increases in size, cause body swelling, nausea and after about 9 months burst out of your vagina and starts screaming at you, you then need to look after it for about 18 years, before it moves away, but still rings you asking for money and bringing it’s dirty washing to your house. Surely that would scare you enough to remember to take the pill at the same time every day! With the modern POP’s you can even be relatively late taking it and be fine.
Next we have the LARC’s: These are the Long Acting Reversible Contraceptives. They are progesterone based and can cause some people to bleed, although normally this resolves and they can stop periods for the full duration of use (and a bit afterwards). The LARC’s include:
Implant: A simple procedure where a small implant is popped into the patients arm and gives contraceptive cover for 3 years.
Injections: A twelve weekly injection that keeps your patient from getting pregnant,
Both these involve needles and so give the patient an opportunity to giggle, when the clinician says “Just a small prick” and the patient retorts: “If it wasn’t for a small pricks I wouldn’t need contraceptives”. Oh hilarious …again!
Then there is the IUD – Intra- Uterine Device! An IUD is a small, T-shaped contraceptive device made from plastic and copper that fits inside the womb (uterus). The clinician inserts it via the vagina…(If it wasn’t for things going in my vagina I wouldn’t need contraceptive…oh give it a rest now, would you?)…and basically it acts as spermicidal barbed wire with a hint of chemical warfare.
Other LARC’s include actually having children, for the next 18yrs you and your partner will be too knackered for sex and on the odd occasion you can muster the energy and enthusiasm, one of you children will cry, vomit or do something else that ruins the mood.
Permanent Contraception: These include “the snip”, getting the man in the relationship so drunk and on so many promises he agrees to have a vasectomy. This contraceptive only works if the female is only having sex with the man who has had the vasectomy!!! Female sterilisation is another option, or becoming a nun, a lesbian, or just abstaining from sex, or better still a lesbian nun that’s abstaining from sex, (although I suppose there’s always the immaculate conception risk! An angel came from heaven…discusting high velocity splatter!)
…and there you have it, the most cram packed 10 minute consultation….Come on! Decide would you?!? Sadly that 10 minutes I spend talking to woman about sex, is probably longer than they’ve ever talked about sex with their partners, or even worse, longer than the act itself actually takes…surely not!Read Full Post | Make a Comment ( 1 so far )
I’ve always played the part of an old git, but as Nurse Practitioners go, I am quite young….Actually I was quite young. There comes a time when you realise that you have more in common with your “older” patients than your “younger” ones. Alas I have passed my 36th Birthday and realised that I am closer to 40 than 30!
Don’t worry, this doesn’t bother me, but I just have to accept that as sure as the leaves turn brown in the autumn, there are signs I am getting older! (Well we all are, let’s face it, from the day you are born you are moving closer to death all the time!!)
The first thing I noticed that told me I was getting on was when those medical students knocked on my office door the other week, as stated previous, I thought it was a pair of 12 year olds doing some late trick or treating dressed as doctors! One was an attractive young “girl”, I felt like taking her home, not cause she was young and sexy, but because she looked too young to be hanging around without adult supervision…
“Does your mother know you’re at medical school?”
Then I find myself on a rare coffee break with the reception staff. The girls that I feel I fit in with because they are young and fab, (like I falsely think I am) are listening to a conversation the “older” staff are having. I join in the conversation and my young friends both say together something wholly depressing like “What’s an LP?” and we weren’t talking draining CSF, but Long Play records… you know a 12 inch?
Yes it’s true my young friends have never seen a 12 inch…I’d offer to show them mine, but fear a slap. Still they probably don’t know what an “inch” is anyway!
Then I call a patient into my room and see they were born in 1990. I should be thinking, hmmm, contraceptive advice etc, but no, I’m thinking: “Where are my “I’ve been good for the Nurse stickers”?” There they stand, not cute kids, not even teenagers, but proper grown ups with their own kids! Had I started my reproductive life earlier, I could be a grandad now without either me or my children having underage sex.
Then the life changing realisation hit me… the next bunch of nursing students to leave school and start Uni where not even born when I started training. The babies I saw being born on my midwifery placement, could soon be nurses!! (Thanks to Kim for the picture!)
The sad thing is in the current climate the older I get the further my pension gets! I’ll be 70, stooped at my desk, incontinence pads on my chair, needing a 12-year-old medical student to listen to patients chest cos I’m so deaf… I’ll be using a dermoscope just to see chicken pox, and unable to test patients for dementia because I can’t remember the questions I just asked… What an image!?
I think I’ll go quiet again for a while!Read Full Post | Make a Comment ( 2 so far )
Since handing in my notice I’ve realised the comic element has evaporated from my blog posts, and actually I make no apology for this. I’ve been here long enough for you to know I am silly so you’ll have to humour my lack of humour for the time being.
This week looks like being no exception. I have 1 week left in this job and the word is out that I am off, this morning I have had two old ladies reduce me to tears already and it isn’t even 9am!
One was in the form of a lovely email, thanking me for various aspects of help I’d given her and a new lease of life I’d given her husband…(hopefully she won’t come in with sexual health problems due to this new lease of life, but you never know).
The other from one of my regulars, not a regular due to hypochondria but a lady who has lots of serious health problems and I have helped her through all of them. I can cope with all the praise of how I have saved her vision and her legs/potentially her life. It was when she said she felt like she was visiting a friend rather than a clinician, that I welled up, so this week I have broken my rules with patients… I gave her a kiss on the cheek as she left, I don’t think my wife’ll be jealous about me kissing 81 year olds…will she??
With six working days left here I’m not sure how I shall cope. The reception team think they may need to block out my last clinic appointments, to stop me sobbing all over the place.
I might cry any minute…
Last week we all went out for my premature leaving doo, everyone was nice and a few people tried to make speeches (despite being intoxicated), I coped OK and stayed fairly sober. When asked to make a speech, I managed about 6 words – “I’m going to miss you all” But then pulled it together, until the waitress said…
“I’m gutted you’re leaving, the kids and I love coming to see you”…. and off I go again.
Well that’s it for me. I am entering a hiatus.I think I’ll have enough to cope with next week and then I’m having a week to lay in a darkened room before starting my new job. Beyond that I’ll try to keep you posted, but I make no promises….
So for now… toodle pip and love you lots! I may edit this post depending on how much I cry in the next 6 days…Read Full Post | Make a Comment ( 4 so far )
As you know if you have been paying attention over the past few weeks, I’m off to a new job and I am sad to be leaving the old one. There are lots of patients that I would like to say bye to and I don’t like the idea of them finding out I’ve left without telling them, (there will be a few I’ll be glad to see the back of!) This is obviously impossible to address, however I thought I’d send a letter to the local free paper and see if anyone reads it!
This is how it went (details subtly changed to protect the guilty!)…
To the people of Sickton-on-the Naze and staff of Naze Medical Practice.
Prior to 2005 I knew very little of Sickton-on-the Naze and the surrounding areas, but on the recommendation of one of your Nurse Practitioners , I came for a job interview to work alongside her as a Nurse Practitioner at Naze Medical Practice. She told me about the surgery, staff and patients and told me how she loved her job there. This made me smile, after all a job is just a job, I’ve always enjoyed what I do, but to “love” work? Surely somewhat of an exaggeration.
The interview went well and I started my job in August 2005. From then until now I have had the most fantastic time in Sickton-on-the Naze. I have made great friends with the surgery staff, and enjoyed meeting the patients here. They have made me smile, laugh and even on some occasions cry. I have shared in their sadness and in their joy. I have listened to them and they to me, we have shared stories. Patients I met as babies are now school children, and I’ve seen spotty teenagers grow into adults and generally watched life progress and feel privileged to have shared in those lives.
One day a patient asked me if I enjoyed my job, and I said that I loved it, no exaggeration. I love working with the team at the surgery, and I love working with the people of Sickton-on-the Naze. For this I would like to say a big thank you and with heavy heart report that I am leaving Sickton-on-the Naze to work at another surgery closer to home. Sometimes it’s good to move on and increase my experiences, but I will be sad to go. I just hope my replacement loves Sickton as I do, and once again I say thank you for letting me share in a little part of life.
Yours Very Sincerely.
Max E Nurse.Read Full Post | Make a Comment ( 2 so far )
This post is a little premature and hopefully unnecessary but I’m going to publish it anyway.
If every cloud has a silver lining, does every silver lining have a cloud?
Last week I told you about my job interview and how I have accepted the job, I didn’t mention that this may have blog implications. Currently I have time in my working day to scribble out a few words a week and post them. I do this during my lunch break and a little between patients if they are running late, or indeed I am running early.
In my new job I will be having shorter breaks and certainly to start with am unlikely to be running ahead of myself. (You know how it goes with a new job, I’ll need to find where they hide things, like the reception desk and stuff!)
They may also have a more strict policy on internet use. The point is at the moment I just don’t know. I could blog from home, but I simply don’t have the time.
You may also have noticed my ability to write weekly posts has gone out of the window a little!
Too busy I’m afraid, and although I keep trying to write regularly, I find myself getting increasingly stressed and down with myself for under achieving.
My concern is that if I have a little hiatus or start blogging less I shall vanish from your subconscious and gather dust next to that toy you’d forgotten about on that shelf. Thus if you love me even a little and haven’t already done it, please do one of the following…
That’d be just lovely. I want this little place to live forever and want to keep adding to it, so I SHALL NOT be giving up, but alas I may fade away slightly, things I may have previously written a full post on may just be shown for your own interpretation on a twitter link, and if you miss me I apologise. I guess that’s all I can say for now…pass a hankey please!
Actually one last thing… (and it sounds a bit final, but I don’t mean it to, it’s NOT like the unromantic man, who only says the important things when it’s too late)… Thanks for all your comments, support and especially to those few of you who I know read regularly…It’s great to know I have regulars!Read Full Post | Make a Comment ( 3 so far )
Sometimes there is a real “urg” in Urgent…
Imagine the scene…It’s the end of a long and tedious day, you’ve been working a full week and scarcely seen daylight as it has now reached that time of the year when you get to work in the dark and you leave in the dark. You only get to see your garden at the weekends…(like some weird divorce settlement). You think you’ve seen your last patient for the week and an appointment slot suddenly appears, with a patient’s details in it and a red line meaning it’s an urgent appointment.
OK, so I don’t want to spend ages doing a full cardiac assessment then waiting for the ambulance and be really late home, but fair enough if it is urgent….
I call the patient, no chest pain, no breathing difficulty, but she does have a headache…could it be a subarachnoid haemorrhage (for those who don’t know a subarachnoid haemorrage isn’t a bleed in an underground spider) or perhaps Meningitis? So I take a history from this rather well looking lady.
She’s had the headache for about 5 years….
Suddenly I think perhaps my adrenaline surge was wasted somewhat.
Why is it urgent? Because the patient has the afternoon off work and she doesn’t know when she’ll next be able to get an appointment….URG!!!
The same thing has happened to me a lot recently. One of the others was also a headache, for several years, that the hospital consultant felt was caused due to cervical spondylosis, but what could be causing the headache…. urm… cervical spondylosis perhaps!
Right that’s it. I want to make a poster for the waiting room defining Urgent….
If you require an URGENT appointment please ensure the following…
You meet one of the following criteria:
*You are experiencing chest pains
*You are having difficulty with your breathing that can’t be resolved with a few slow deep breaths into a paper bag.
*You have had your symptoms for a few hours only.
*You really do think you are about to die.
You do NOT meet any of the following criteria:
*You need to be seen today as it is not convenient to be seen when the next routine appointment is.
*You’ve Googled the symptoms you’ve had over the last few months/years and now convinced yourself your demise is imminent.
*Your boss said you need a sick note before tomorrow
*You have several days of pain, and want a prescription, but haven’t taken anything from the pharmacist to help.
*You’re a bit bored and happen to be walking by the surgery when you saw the lights were still on.
*It’s raining outside.
*You only have one week left on your prescription.
Do I think it will help??? NO!
Anyway with Christmas fast approaching I will invariably be inundated with urgent cases that “wouldn’t have normally come” but… “don’t want to be ill for Christmas!” ‘Tis the season to be a wally….Tra la-la la-la, la la la aarrrrg!Read Full Post | Make a Comment ( None so far )
This week I feel good.
Mr Brown is awaiting his hip replacement
Most of the time I see my patients, I feel I do my job well, and sort out whatever it is they have dragged their sorry arses in to the surgery to see me about. Sometimes they have to come back and try something else which will work, or I’ll need to refer them on to someone with specialist knowledge (or just someone brighter than me!)
Last week I exceeded my usual ability to resolve short-term problems…Here’s what happened. A 78 yr old with phimosis (that’s foreskin tightening to those who don’t have the misfortune to already know!) presented as the end of his foreskin was itchy and red. I asked him about how long it had been a problem and he said the rash was only there for a few days.
When I asked about the phimosis, he looked surprised and said he’d been like that all his life, or at least as long as he could remember. He thought it was normal for his foreskin not to retract…”surely that was only for circumcised men”…
Sorry America…this is Britain Uncut!
So I gave him a prescription for some clotrimazole cream, and said he need to return in a week so I could see if anything much had changed, I wasn’t hopeful with such a basic treatment, but I needed to start somewhere.
One week later he comes back impressed as anything, as he can now fully retract his foreskin. Not often can you resolve a life long problem with a £1.84 product!
I wonder what he found under there!
And then of course there are all those people who come in limping and coughing and leave without a cough or a limp…. the laying on of my hands must be miraculous!
Anyway enough bragging!
For every one miraculous occurance, their are aproximately 3 who leave muttering: “What a waste of time, he didn’t even give me any antibiotics”. But lets not go there!Read Full Post | Make a Comment ( None so far )
A patient came in today complaining of having a sore throat, runny nose and feeling awful…
I assessed him and advised him that he appeared to have a virus…not an uncommon occurence, but the fact he told me he was feeling awful sort of amused me, then started my brain ticking…(oh no!!)
Why do viruses have to make us feel awful? I appreciate this microscopic life forms need to reproduce and spread from person to person to keep their existence, and as annoying as this is, it is basically the same as any other life form on the planet, so good luck to it. If the survival of their species is the only reason colds and other viruses exist, would it make evolutionary sense to encourage the host (AKA us!) to stop trying to get rid of them?
Surely if viruses evolved to make us (the host) feel good it would become a happy symbiotic relationship, a bit like the bird that eats the annoying bugs off the hippos back, leaving the hippo less irritated and the bird fed (only the poor bug loses out!)
3 birds on his back…Sounds like being married with two daughters to me!
Why can’t we have airborne viruses that make us feel energised and full of the joys of spring with a euphoric bounce in our step? If this was the case then people would want viruses, we would feel great when we had them and the virus would be encouraged to thrive. Sure you’d have some virus abusers, trying to get a viral fix all the time, but perhaps it’d cut down on drug abuse. See now I’ve ruined this idea with a vision of slutty dressed girls going up to greasy old men in clubs, and slyly whispering in their ear…”Eh mate, fancy a virus? 20 quid???”
There is a down side to every nice thought…what’s that expression…Every silver lining has a cloud?
My original nice thought was this…
Pt: “Good morning Max! I’ve had a virus and I think it’s gone to my chest”
Max: “So what symptoms did you have and when did they start?”
Pt: “Well before the weekend I started with a tickle in my throat, really made me giggle and feel happy, then I think I had a raised temperature because I felt like someone was giving me a nice warm hug all day, but over the last few days my chest has been tickly as well. I’m sure it’s just a virus, but would you mind listening to my lungs and check?”
Max after throughly examining the patient: “Your chest is as clear as a bell, it must just be an Upper resp-giggle-tory infection. The bad news is it’ll be cleared up in a few days”.
Max!! Max!!! STOP dreaming….my nose is streaming!Read Full Post | Make a Comment ( None so far )
Read Full Post | Make a Comment ( None so far )
I consider myself spiritual, but not particularly religious… Lets leave it at that… but today I shall start by quoting the bible….
In everything I did, I showed you that by this kind of hard work we must help the weak, remembering the words the Lord Jesus himself said: ‘It is more blessed to give than to receive.’
Wow!!! I feel better for that!
Anyhoooo, where am I going with this. I’m definitely a “giver” at work.
I give to my patients my time, my experience and expertise, handsome good looks and a listening ear…as shown in the following picture…
But sometimes on the battle front of primary care, it is the patient that gives and I who receive. The things I receive are not flower or chocolates, but health care battle wounds….
Patients give me….
Urine samples in bottles not designed to have urine samples in them. Some make patients appear diabetic when they are not (you really mustn’t put wee in honey pots!) and others in pots that seem to be specifically designed to ensure the contents goes anywhere but on the urinalysis stick. (Yes! I am writing this post with someone elses urine on my trousers!)
Flying microscopic bugs. Debatably when you sneeze the bugs and grubs that come out along with all that forced air travel at 100mph. Coughs are less speedy, but probably more germ ridden….please don’t aim them at me, and as I have said before the Peak flow meter is not a germ pea shooter, face away from me.
Flying macroscopic bugs: Tic’s and flea’s and head lice! No thanks. I believe you, you really don’t need to get any closer!
Pus. OK it’s not your fault, but your abscess just erupted…(all the following have happened to me and I feel a little poetic…)
I squeezed your big juicy spot
Messily it erupted like it oughta.
See that gunk and watch it fly.
Nearly hit the picture by my daughter.
Pus now dripping down my tie,
across my keyboard and into my water,
and somehow just missed my eye!
So, as you can see my job is give and take. It’s a war zone and I stand up and take my place to fight, but if you could keep the above ”gifts” to yourself….and bring me some chocolate I’d appreciate it.
This post was slightly motivated by getting wee on my trousers and slightly by NYCRN’s new blog “Pee and Sympathy” and his Nurse manifesto.
All this talk of war zones in humour at this time of year, lets not forget the real heros…
I have a battle just trying not to lose my poppy, still it’s for a good cause so I’ll just have to buy another!
Well it finally seems to have happen..I think! (hmmm, I’ll rephrase that before someone makes a smart arse comment about me finally thinking…)
Well I think it has finally happened!
No not that!
When I first started out in General Practice, I felt a little intimidated and a lot impressed when I went to the Doctors and asked advice on a particular patients care and, on just hearing the name, they would rattle off about that particular patient as if they had memorized their notes. I mentioned this to one of them, and they said…
“You’ll be the same in a few years!”
Surely not! I have a slight disadvantage, the GP’s usually see their own patients, and as there are 5 GP’s they only have a 5th of the patients to deal with, whereas I see everyone. Now I am less naive I realise the GP’s can’t recall every patient, but it seemed that way because on the rare occasion I go to them for advice, it is usually about a regular with complicated issues, and thus their Doc knows them quite well.
So yesterday was a sunny day, and I went for a lunch time stroll around town. I realised that several patients smiled and said ”hello” to me.
I’m always cautious about saying “Hello” first. I suppose it’s a bit of a confidentiality issue, if I say “Hello” then everyone in the street might realise they’ve been to see me, especially as I live in a different town. Mind you it’s not like I say:
“Ah, hello Mrs Smith and Mrs Jones. So Mrs Smith, how are those tricky piles today? Mrs Jones I trust you’re wearing a good incontinence pad, after all you’re a long way from your house! Ah young Charlie is over the road….’Afternoon Charlie, how’s the crabs?!”
Instead it’s a nod and reciprocated “Good Afternoon” if one is received, and a half smile and nod to Charlie on the way down the road.
Psst, how’s the crab’s?
After all it’s not just about confidentiality, it’s my bleeding lunch break!
Anyhow, I’m walking down the street, several patients saying “hello” (what’s the plural of Hello? Hellos, Helloses, Helli, Hell I don’t really care!) and I look around, I see a Schizophrenic chap walking up the road, and then I see the woman with depression, and that bloke in the motor scooter with diabetes, who I have recently started on levothyroxine, and over there is one of the twins, with her friend who just had an unplanned pregnancy and didn’t know how to react when she had a miscarriage…and then I realise it’s happen!
No! I haven’t developed that ultimate nurse super power of being able to diagnose people just by passing them in the street, (Is it just me, or does anyone else pretend that they can do that when walking along sometimes!?!? It’s not crazy, it’s just like people watching with a diagnostic twist – hmmm, OK sounds a little nuts!)
I realise I now know enough of my patients and have had enough encounters with them to know who someone is and be able to recall a fair chunk of their medical history, just like the Doc. said I’d be able to!
So I feel a little strange about this occurence. Is it time I moved to another area? Am I now part of society in this area, someone who is known by lots of people in the town?
I go back to my consulting room feeling like some kind of local celebrity, part of society, intergrated into the towns folk law of the future. I call in my first patient of the afternoon and I get greeted by….
“Oh hello, I was expecting a lady Nurse Practitioner, are you new here?”
The next thing I hear is the thud as my feet land firmly on the ground!Read Full Post | Make a Comment ( 1 so far )
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