I Dun Fixed That Mailbox...

Today we got an e-mail from our grant administrator notifying us that our little homeless program scored an "A-" rating from the federal oversight office.

I'm a bit offended by that minus sign. Why bother giving us an "A" if you are just gonna toss a minus behind it? I would almost prefer a "B." Almost.

See, my contract is up for renewal in November. That "A-" gives me the leverage to go in and ask for a 20% raise.  They'll probably offer me 10. I'll push the issue for 15. I'd settle for 12. But don't tell them I said that.

More good news came last week when I got word from the Nursing Education Loan Repayment Program that they are going to pay back the majority of my outstanding student loans. Hands together in prayer that the contract gets finalized. Even if its not, thank the Lord anyhow.

I've been struggling to write this blog entry for the past  3 days. Its not for lack of material. But sometimes its difficult to frame all I want to say in the way that I want to say it. Like I said before, I have a million stories. I want to include the ups, the downs, the joys, and the sorrows of what I do, but I don't want to lose focus on my purpose here.

Yesterday, CK came to give me report on a new patient that had been added to the schedule. Not unusual. But here is the kicker.

She was pregnant. And HIV positive.

I have a rule.

I don't touch pregnant women.

I have seen pregnant women on the rare occasion for colds, and rashes and bladder infections and all that good stuff. In most cases, I will treat them with medication if the drug I am going to prescribe is Category A or B. Anything else and I send them to see their OB provider. The crazy thing is that I've also had OB providers send their pregnant patients to me to manage things like blood pressure or diabetes. But if they don't know, why do they think I do???? I know a little something about birthing babies. But I also don't like what I know. So I don't touch them. Creates the potential to kill 2 people at once. And ain't nobody got time for that.

And HIV patients?

I also have a rule.

If they are already seeing an HIV specialist, that means that they are covered under the Ryan White Grant. Technically, I am not allowed to see them and they must see their HIV provider. In that case, we'll call and get them an appointment to be seen. If they do not have an HIV provider, I will see them, do the initial work-up and HIV panel and refer them to an HIV provider. In either case, if they are sick that day, I will see them and treat them if I can and have them follow-up with their HIV provider immediately. As with any patient, I try to avoid having too many cooks in the kitchen.

Especially if an HIV patient in on anti-retroviral therapy (ART), I am cautious about providing care. Those type of medications interact with EVERYTHING. For example, if an HIV patient is on ART and they come to me to be treated for reflux, it would be simple enough to put them on Prilosec. Except that Prilosec is a proton-pump inhibitor and interferes with how ART works. That doesn't mean they can't take it. Just means that someone more schooled in that arena should make that call. Not me. I know my limits. And that is one of them.

So anyway, this patient is pregnant and HIV positive. She did have and OB as well as an HIV provider who she saw regularly. I tell CK that if she has a minor issue, I will see her. But if she was here for anything related to the HIV or her pregnancy, we'd have to send her somewhere else.

CK tells me that she has a "rash" on her leg and thinks something may have bitten her.

Sounds simple enough. I agree to see her and  CK brings her back to the exam room.

The patient tells me that she noticed a quarter sized red spot on her left lower leg the day before. It was painful, but she thought nothing of it. When she woke up that morning, her entire leg was red, swollen and painful.

I started to exam her leg and noticed that not only was the leg red and swollen, but the patient jumped off of the table at the slightest touch of my fingertip and her leg felt like the top of a warm stove.

Immediately, two things came to mind:

A blood clot or an infection.

I did not see any vector wounds or anything that looks like she might have been bitten. The redness in her leg was diffuse, but streaky and looked to be moving upwards. It had progressed quickly over 24 hours. The swelling was only mild and I'd felt much warmer extremities in the presence of clot. She did not have any calf pain. Her pedal pulse was normal. Her Homan's sign, although neither very sensitive or specific for a blood clot, was negative. She could bear weight, had no chest pain or shortness of breath. She did have a low grade fever. Other than the specific complaint about her leg, she seemed to be fine.


My money was on the infection. I could hit her with Category B Keflex four times a day for a week. But the fact that the cellulitis developed without a point of entry meant that her immune system was compromised. And doubly so by the HIV and the pregnancy. The oral antibiotics might not make up enough ground for her weakened immune system. Even if it would, with the way our pharmacy services worked, it would be 24 hours before she would get the medicine.

And what if it was a clot? Although the presentation wasn't classic, stranger things have happened. If I let it go unchecked for a week, with her risk factors, that was asking for trouble.

I may have been over thinking it all. But the best thing was to send her to the hospital. They could decide whether to treat with oral vs. IV antibiotics and rule out a clot immediately.

So I asked CK to call 911.

Not a big deal in the grand scheme of things. But I remember when I worked as a floor nurse, a physician told me that calling the MD after 11:00 pm was the sign of weakness in a nurse.

Not that I believed him. If I had patient going bad at 3:00 in the morning, getting cussed out by the doctor for waking him up was the least of my worries. But just like most people, I have an ego. Especially when it comes to my competency as a provider. And calling 911 felt like a weakness in that moment.

See, I'm not used to asking for help. I never really learned to, because I've never really had to.  Maybe because in most places I've gone, I ended up being the smartest person in the room. Maybe. Or maybe I just need to find better places to go.

Even in school, I hated group work because the pace in which a task got finished was dictated by the slowest person in the group. When I took Microbiology, I had the worst lab partner....ever. Its wrong for me to say, but when she withdraw because she was flunking the lecture portion of the class, I went out and had a drink after class to celebrate.  This meant, I could finish the course by my lonesome.

You see, my preference is to take full responsibility for anything I do. No matter the outcome. I hate sending patients to the emergency room when I know that I know what's wrong with them and I could potentially fix it.

But I've learned, that as it relates to many things in my life, its just really not about me.

I could not compromise this woman or her unborn child for the sake of my ego. The chance just wasn't worth taking.

So off she went in the ambulance. With me sitting at my desk second guessing myself.

As I was leaving work that day, I ran into this patient on her way back into the shelter. She walked up to me and said, "You were right. They said its an infection. But they did do an ultrasound to rule out a clot because I'm pregnant."

They gave her a weeks worth of four times a day Keflex and told her to follow-up with her regular provider if she did not improve or got worse. I half-nodded at her offer of thanks and went on my way.

It will sound crazy, but it gave me no satisfaction that I was right. 

I want to be the one to "fix" my patients.

Just like Mister fixed that mailbox.

So's I know when theys been messed wit.

Towanna