Sunday, January 30, 2011

What is a Nurse Practitioner? (another old post reposted)

I was saddened to see an advertisement in the local paper for a new clinic which will be opening up. I'm very happy about the clinic and the fact that a good friend of mine will be the Nurse Practitioner (NP) there. She starts in a couple of weeks. Until then, another NP friend of mine is filling in. They had a ribbon cutting ceremony and pictures were taken outside the building for the local paper. This photo included staff members from the clinic, including a very professional-looking NP, the clinic manager, a "supervising physician," and some local "important people." All this looks great on the surface to the casual observer. Then I read the article. The only mention of the NP was to say that she is "a good listener." Well so what?? Plants are good listeners. Don't get me wrong, listening is a skill that all medical providers need to master, because most of our work is accomplished and proper diagnoses are made because we listen; but one must have an education and some experience with diagnosing and treating illness to go along with those listening skills. I happen to know this particular NP has excellent diagnostic skills, which is what a patient needs to be assured of when seeking out a healthcare professional. Why do you think patients seek out the most qualified person for the job when looking for a healthcare provider? I can listen to her all day, but if I don't know how to diagnose or fix the problem, I'm not of much use to the patient.
The second issue I have with this article is the fact that a medical doctor was interviewed for the article and will have very little to do with the operations of this clinic. You see, in Tennessee, nurse practitioners are required to have a doctor come in and sign off on 20 percent of our charts (100 percent of any charts where a narcotic is written). This does not mean we are working "under the doctor," as so many imply. We are working under our own license and our own DEA prescribing number. They are simply paid to review some charts and put a signature on them. You see how ludicrous this is. Don't get me wrong, the doctor they interviewed is a wonderful guy, and a great doctor. I simply find it so sad that we feel we must give patients the illusion that a "real doctor" is somehow involved in operations of the clinic.
For those of you who don't know, NPs have at least at Master's Degree, which is 6 years minimum. For many of us, it also includes several years as an RN before completing those years of school for the NP degree, which was a priceless part of my educational process. I want to spread the word that we are here to stay, we don't need to hide behind a doctor's name, we have one of our own. Patients have a choice to see us or not, we are not pulling the wool over their eyes or trying to be deceitful just to get patients.
Most NPs, like most MDs do a good job. I urge you to see the difference for yourself. You may not notice any. You may have a bad experience. You may find the provider you want to stick with as long as you live. I just ask that you know who you are seeing and that you give the credit to that person alone for the care they provide.

Working Weekend (old post re-posted)

I worked in the hospital this weekend
Convincing people
That they really did not need to be there.
That a hangnail could be treated as an out-patient;
And that going out to smoke every 30 minutes
Well - probably was having a negative effect on the outcomes of the care I was Trying to provide.
That swallowing a toe ring
Probably had nothing to do with the abdominal pain.
What did you do this weekend?

p.s. don't try to figure out who these patients were, I made it all up.

"He Saved My Life!"

Nurse Practitioners are becoming more recognized by healthcare organizations because of our financial contributions to the bottom line, and salaries are finally starting to reflect that. However, if you think for one minute that you will be recognized for your excellent exam and diagnostic skills, you might consider getting your head out of the sand. Granted, there will be that one physician, and the handful of patients who notice when you are able to diagnose and treat something other than a sinus infection or UTI, but beyond that, most people we care for would prefer if you call an emergency consult with the pulmonologist for their community acquired pneumonia, or the gastroenterologist for their chronic abdominal pain cause by too many narcotics and blocked plumbing.
So you diagnose this CVA, after the patient was admitted with sinusitis and "cant swallow," you start Plavix, order a swallowing study and rehab, and for safety's sake, you order a Neuro consult because it's expected. Nothing will kill an ego quicker than for a family or patient to say " yeah, that Dr Saint saved my life, I know he did, he's really good ." the appropriate response to this is NOT " oh, actually I did that!" Although that's exactly what we want to say, it's not very good PR for when you really need the neurologist. Just agree and "manage up" your specialists, it will get you much more respect and the patient will at least realize that you, the nurse who "almost made a doctor," are part of the TEAM that has provided the best care possible. This is the part where you take a deep breath, roll your eyes (don't let them see you,) and smile.

Saturday, January 29, 2011

We're Not Going Away

As I browsed my twitter account today, I came across a post that mentioned me and was curious, so I clicked on the link and found that I couldn't just sit by and let his post stand alone without a rebuttal.  Dr. Wes was confused as to why I was a "self-procalimed" hospitalist NP.

You see, I work in the hospital setting with a group of physicians that care for inpatients when their primary care providers choose not to come there. This group of providers is called "Hospitalists." Therefore, I am a Nurse Practitioner Hospitalist. As far as I know, there is not a copyright on this title or the title of "doctor" or "physician." Do I introduce myself as a hospitalist? No (because patients still have no idea what that is). I always say I'm a nurse practitioner (most do know what that is in our area, as we make up the majority of primary care providers in our community), and I tell them what I do. Depending on the patient, I may say " I work with the hospitalist program," or I may just say "I work with the hospital's doctors' service (because let's admit it, everyone still calls their provider a doctor whether they are or not), we take care of you while you are in the hospital, and we communicate back to your doctor or nurse practitioner what happens while you are here." I tell them the name of the physician I'm working with that day, and that we work as a team. This description of what I do has not caused any confusion among my patients, although clearly it's the quick-to-remind-me "real doctors" who are confused.

Initially, I took it personally (for all NPs). Then I read a few more of his blog posts, and realized I am just small beans in the huge pot of paranoia stew. To add fuel to the fire in my butt, he sent me a message that said "No doubt you're great, and relatively cheap, for your hospital-employer." I had to tell him that the hospital does not employ me, a group of physicians does, and of course it's all about the money. In turn, I asked how he would feel if he were referred to as "over-priced." No response.

In another tweet, he said it "devalues our degrees and hospital-employers are encouraging this. Doctors should take notice." Really? My employer is a physician owned group of providers who provide services to hospitals (not hospital-owned).  The hospital pays the same amount monthly for our services, so obviously, again, it is about the money as I make one half the salary of my doctor/supervising physicians, making it possible to have more staff available for the same price. However, they have a job much more difficult than mine, including seeing and signing all my charts, seeing the critical care patients, and taking call 24/7.  Our company, and many others, realize the quality of care they get for the price with NPs, and when they pair us up with a quality physician, they get more bang for their buck. Insurance companies reimburse for our services at 85 percent of the physician fee, we work under our own license (not the physician's,) we cost half the price of a physician, so anyone with any financial accumen at all would see the benefit in this.

This was the second physician I've been in contact with recently who needed a little education. One of the orthopedic docs I work with recently said to me, when he was looking for someone to do rounds and help in surgery (and he thought he needed a PA, but I suggested one of our NPs who worked in acute care), and he said "nurse practitioner, that's like LPN, right?" Seriously.

This article is a great complilation of just a few of the studies that have been done to demonstrate NP competency and quality of care, as well as patient satisfaction (which is the ultimate quality indicator).

It really doesn't have to be "us against them," but sometimes it sure does seem that way.

Low Carb

Since it's the beginning of a new year, I usually try to start out by making some healthy changes. I'm happy to say I stuck to a healthier diet for the most part last year, more than previous years. UNTIL the last couple of weeks of December, then I ate everything in sight it seemed. Diabetes runs in my family, so since I am not getting any younger or thinner as each year passes, I am trying to ward it off as long as I can.

If you or someone you know is diabetic, I'm sure you have seen all the conflicting information out there regarding diabetes. As a nurse practitioner, conversations with diabetics or pre-diabetics are a part of my day - every day. What I have found is:

1. diabetics are confused

2. too much information is bad sometimes

3. due to time constraints, there is no way to get into all the "details" of dieting.

How do I know who to believe, what to read, what to eat/not to eat? If you will follow a few simple rules, whether you are diabetic or just want to lose a few pounds, glucose levels will come down; and, even if they are not "normal," I'm sure you will see a major improvement in your energy level and lab results.

When I have 5 minutes to share with someone, I advise them to follow the "No White Diet"  In other words, if it starts out white and powdery (cocaine doesn't count), it will "run your sugar up" and cause you to deposit fat around your abdominal area. So what's considered "white?"
*corn meal
*potatoes (ok, they are not powdery but they ARE EVIL)
Remember, if it CONTAINS any of these ingredients, it's high-carb.

That means NO SODAS unless diet

No JUICE unless tomato or V8 vegetable (not the fruity kind) - fresh fruit is ok in moderation, but avoid over-doing it with the bananas. No canned fruit.

If you eat bread, limit it to one or two slices of very high fiber bread : I like this one:

(note it says "double fiber")

The good news: EGGS are white and they are ok - eat up! Try an omelet made with your favorite cheese and salsa, or do what I did and stuff it with your left-over New Year's Eve Spinach Artichoke dip - Amazing!

I will post more of these notes and low carb ideas if anyone is interested. Feedback is welcome.

Here's a link to a reputable medical journal research study in case you are interested:

*Pink shirt above is available HERE

Monday, January 24, 2011


So your day is going along pretty well and you are checking off labs that were drawn on your patients yesterday and you come across Jane's labs showing a sodium level of 125. Normal sodium concentation is 135 to 145. What do you do?
1). Call Jane and ask her to come back to the clinic today.
2). Tell Jane to go directly to the ER.
3). Tell Jane to get a salt lick and come back next week.
4). Nothing, ignore it and hope it will go away.

Low levels of SODIUM in the blood = HYPOnatremia
Worry more if it's below 120.

The first thing I would do is ask Jane to come back to the clinic. If that is not possible, try to do a phone interview to decide if it's urgent that she go to ER or come in. Document the conversation either way.

Let's assume Jane is the ideal patient and comes right on over to the office. Look at her: how does she appear? Is she the same Jane you saw last week/last month? Is her mouth dry? Is her skin dry with poor turgor? Is her blood pressure low? Check it lying and standing, does it drop (20 points)? Does her heart rate go up (more than 20 points) when she stands up? Is she having any new symptoms? Has she been having headaches, nausea, vomiting, confusion? Hopefully if she's having seizures or coma you would have heard about it by now (?) but you never know. If Jane looks pretty normal, this is probably not an acute change in her sodium and it has occurred slowly over time.

If Jane has no reason to be dehydrated, ask her if she has been drinking excess fluids. I mean EXCESS, as in several liters a day. Does she have any swelling? Does she have crackles in her lungs with deep breath? Does she appear short of breath as she talks to you? Has she been having trouble breathing when she lies flat? Has her urine been very dilute/clear? Or has it been very concentrated and voiding small amounts or not at all?

At some point you will decide whether this can be treated at home or in the hospital. If in-patient treatment is not necessary, consider nephrology referral as they are great at helping us sort through these causes and treatments. In the hospital, referral will depend on level of comfort and response of the patient to treatment.

 Hyponatremia from whatever cause has only one physiological cause: Water Intake must have been greater than Water Excretion.

Here I will review three types of hyponatremia - from low volume, volume overload, or normal volume (if you are already sleepy you might want to skip this part and come back later).

Low volume:
  • Causes include; vomiting or diarrhea or excessive use of laxatives, excess use of diuretics; osmotic diuresis (due to hyperglycemia in untreated diabetes mellitus)
    "3rd Space"
  • S/S: Look at other lab data that indicates low volume status - hemoconcentration: increased albumin, BUN, and if severe, increased CRE, decreased urine sodium (the Urine Na is often Low (i.e. below 20 mEq/L) except when the patient is taking a diuretic)
  • Urine output is low - why? Because decreased volume increases ADH release (your body says "wo! I need to save water!") so renin is increased and angiotensin II levels, which causes increased reabsorption (water retention). Therefore, total amount of dilute urine that can be generated is low.
  • Treatment: isotonic saline (Normal Saline); discontinue any diuretics/laxatives
    Increasing fluids will increase the volume and ADH will be turned off and sodium CONCENTRATION will normalize. This needs to be a slow process, replacing too fast causes
High Volume
  • Causes: CHF, SIADH (often caused by cancer), Psychogenic Polydipsia
  • S/S: hypertension, SOB, orthopnea, rales on exam, edema (although we can retain 3 liters of extra fluid before edematous), increased LFTS from liver congestion, JVD.
  •  Diagnostic clues: decreased albumin, hypoxia on ABGs, peripheral vascular congestion on CXR
  • SIADH explained: (same as infused ADH): Remember, this is ANTI-diuretic, so it's doing the opposite of a diuretic ; Urine Na is often high (over 20) unless patient is on diuretics. SIADH is sometimes associated with certain types of cancers, but that's another lecture.
  • May not have edema because you can retain up to 3 L of saline without getting edema. 
  • Why? ADH is increased, which means the body holds water, the retained H2O dilutes the total body water - a portion of this is the intravascular volume, hence serum Na is decreased (diluted) and the volume increases.
    The increased intravascular volume and suppressed angiotensin II and decreases aldosterone secretion. Therefore less Na is reabsorbed distally, therefore you pee out more sodium and urine sodium will be high
  • Treatment: fluid restriction, lasix, no 3% sodium unless critical symptoms, better to try demeclocycline to block the action of ADH in the kidney.
 Normal Volume:
  • Causes: One rare cause is Psychogenic Polydipsia where water intake is greater than the kidney's ability to excrete dilute urine (about 20 Liters /day).
    • Common Cause include decreased "Effective" Plasma Volume where there is arterial underfilling. This is seen in Heart Failure (low output), Cirrhosis(low proteins) and Nephrotic Syndrome (protein loss). Such patients often have edema. Other causes include hypothyroidism, hypopituitarism and reduced glucocorticoid activity as in Addison's disease (you'll have to look these up because I don't have time right now).
    • Decreased Effective Volume also increases ADH release, which increases renin, and angiotensin II levels, which in turn causes increased reabsorption of water (aka water retention). Therefore, UOP is low.
  • S/S: body weight likely to be same, no orthostatic changes, urine sodium is often low , decreased UOP
  • Treatment  Water Restriction
Summary: Restrict fluids to 1 liter daily unless Jane has low volume, in that case she will need to have IV normal saline to replace fluids that were lost and discontinue any diuretics or laxatives.

For those who work in ER or Critical Care, he's a great link as well:
Please leave comments, I know this is incomplete in many ways, and too much information for some of you, but hopefully there are some PEARLS you can use in your practice.

Sunday, January 23, 2011

Start at the Beginning - The Introduction

When the idea for this blog came up, I had multiple medical topics in mind that I have dealt with since working as a hospitalist NP.  However, I wanted to have some type of order to this, not totally random like I usually am, so I think we will start with what I think is the most important aspect of the patient experience: First Impressions.


SMILE! It really is contagious :)

Introduce yourself to everyone in the room. You'd be surprised how many times we walk into a room and just start talking. Imagine if you were the person lying there and this PERSON just starts spouting out numbers and words that may as well be Latin as far as you are concerned.

Be confident. Once upon a time, this was a hard one for me, having a fairly passive personality,  I wanted to say things like "we are going to try to figure out what's going on," or "wow, you really are sick, I don't know if we can help you or not but we will try."  Now, wouldn't you feel just great if you were sick and the one person in the whole world who at this moment is able to help you doesn't even seem sure he/she knows where to start? Wouldn't it make you feel better if your healthcare provider said "Hi, I'm Jane, I'm a nurse practitioner here, and I will be taking care of you today. I know you are feeling really lousy, but we have a great team of doctors and nurses here with years of experience with this sort of problem and I just want you to be assured you are in good hands."

I know these seem like basics and you probably are saying "Really, Kim, did you really think you had to tell us to do those things?" Truth is yes, I know, because everything I post here is and will be from experience. In other-over-used-words "been there, done that." The hard stuff will come later.

Don't forget to comment and let me know what topics you'd like to see in the future. 

Hello World of Healthcare Blogging!

Since I'm such a nerd, I thought I'd start a little blog for my nurse practitioner (NP) peers in cyberspace (or any others who may be interested, but I'm not so crazy to think this will be of interest to non-medical field geeks). Anyway, just when I thought I was finally in my comfort zone in primary care, an offer came along that I couldn't refuse and I found myself back where I belong - the hospital. Working as an NP is never dull, and with the changes, I have had the opportunity (a.k.a. requirement) to look up more "stuff" than I've had to in other jobs. When I look things up, I must write them down to help remember them (did I mention I think I have early onset dementia from banging my head against a brick wall in primary care?) So, I figure if I'm writing them down, I should share them with you, and maybe when/if the situation comes up in your practice, you will remember something we discussed here and can move on (and you can remember you read it here - on the nerdy nurse blog). 

I hope to come here weekly or at least bi-weekly and post some random facts (or opinions). Sometimes I may not have the answers, only questions, and I look forward to your feedback and opinions.

Please introduce yourself under comments if you are here reading this. Otherwise I will have no clue that you were here and I will feel ignored, my feelings will be hurt and this blog will be a mere dream...the dreams of a nerd nurse will be smashed. History. So, thanks  in advance for your comments.