Wow! What a year this has been and with each opportunity and experience I have been able to share, I have the ADVANCE community to thank for helping me to grow and be a better professional. I have met so many wonderful people who continue to offer support and challenge me with my every day struggles as an NP working in corrections.

Over the past several months I have had wonderful experiences attending my local association of advance practice nurses as well as regional conferences. I enjoy education and learning, and the venues are not bad either. I look forward to these meetings because I can interact with like-minded professionals and the education is phenomenal; I strongly encourage new NPs to join.

While working in corrections and even taking calls for the 60 nursing homes as my second job, I do not have the opportunity to interact with other physicians and representatives and at times, I feel like I am missing out. I once heard that NPs are transient, meaning they only stay in a job for about two years; I really do not know if that is true. I have met several professionals who were in positions that were not a great fit, and possibly for some it takes several opportunities before that happens.

There have been some interesting changes over the year: the ability to prescribe Schedule II medication is a significant one, but I have to admit the education required is confusing for me, so I have taken the six hour course and any continuing education I can through the AACN and AANP. 

Another change that has come for me is my resignation to the correctional facility. Initially, this was a great fit for me. It has been a great first job, but as life goes there have been many changes. First, with the release of the contract of my collaborative physician and the hire of the current suggested by corporate that it is not about quality.

While I continue to keep in contact with staff there, it appears that it has gotten worse. The most recent is thirteen inmates were admitted to the hospital over three days. This never happened when my first collaborative was employed, nor when I was there and I do not want to be associated with this type of neglect. Also, there was a female who had been incarcerated for over a month. It was reported she became ill after overdosing on an "over the counter medication." She was rushed to the ER where she died.

I still feel every ounce the neophyte but am pleased to share with any new clinician that as the days pass a feeling of authority and competence will slowly replace the choke hold of anxiety associated with the responsibility of diagnosing and treating patients.

From one new practitioner to another, I have included some tidbits to help surmount the inevitable challenges associated with this work and ultimately dominate the passage of time.

1. Do your research and shadow another NP during their routine work day before deciding to accept the job
2. Ask for CME funds as part of your hiring negotiations
3. Utilize resources like Uptodate often
4. Approach your job in the same studious manner that you approached your exams: this means a lot of reading outside of work
5. Always ask for help
6. Follow up with your patients, their labs and their imagery studies
7. Become familiar with the medications you most often prescribe, e.g. dose, drug interactions, side effects, safety in pregnancy, duration of treatment, frequency of administration
8. Seek peer review
9. Always work to refine and improve your documentation skills
10. Leave the position if you don't feel well supported
11. Practice prescience, always think about where you are now and where you want to be in your practice - set both short and long term goals
12. Never forget, nor overlook your nursing background

Every day is an adventure at the correctional facility and at times it is not from the inmates. Oftentimes, it is from the person I like to call "The Lovely Doctor." I do not know why I call him that, but maybe it is because it is the nicest name I can call him...yes! It is sarcasm at its finest.

One of the perks that has been rescinded while working downtown is our prime parking spots. Due to intense construction and what some call progress, the courthouse staff and medical staff have been relocated approximately 2 miles away from the facility. The up side is, we still do not have to pay for parking and we are being shuttled to and from the parking lot. I always try to find a positive in a changing environment, and I have. While we are shuttled to the building, I walk back to the parking lot which is a great way to unwind at the end of a long, trying day and get exercise at the same time.

Now back to the lovely doctor: One rainy day I decided to wear a ball cap and I spoke to him when he boarded the bus. When we exited the bus, I slowed my pace to match his. Clearly, he did not know who I was, so I hastened my pace and entered the building. While I was preparing to see the patients, he came to my office and asked, "Was that you in the hat?" I had to laugh because I did not realize a ball cap was such a great camouflage disguise.

My collaborative calls in sick at least once or twice every other week; he informed me, "I know people don't think I have been sick." I did not say anything to that. Back in the summer, my collaborative called in sick because he went to an amusement water park. When needing to use the facilities, he forgot to wear shoes. He stated, "I burned the bottom of my feet!" I asked, "You didn't wear shoes?" He is a piece of work.

Two weeks after that call in, he called in and proceeded to tell the secretary, "I had to pull along the side of the road and throw up." The secretary said, "Ok, ok, that is a visual I did not need," especially since she was pregnant. My Health Service Administrator says quietly she hopes this nonsense won't last much longer, but it will because the corporate office has not received any complaints. My collaborative states, "I have been waiting all my life to find a job like this," and unfortunately he will probably be around a long time.

I wrote a blog much earlier this year discussing the importance of abstaining from treating asymptomatic UTIs while making a feeble attempt to include a Harry Potter reference. This past week, a favorite patient of mine, an older woman who has been hospitalized repeatedly for an ESBL UTI and bacteremia called our office in a panic.

She was scheduled for a cystoscopy and her urologist requested that she have a urine culture performed in advance of the procedure. Her urine culture revealed an Enterococcus species that was resistant to everything except for Vancomycin. This is a problem.

Vancomycin can only be administered intravenously in the setting of treating Enterococcus. Plus, she was totally asymptomatic: no dysuria, frequency, urgency, supra-pubic pressure, pyuria, hematuria, fevers, rigors, nada. This means quite simply that her bladder is colonized with Enterococcus. While not optimal, this is not a problem that warrants treatment.

Do you treat an asymptomatic octogenarian with multiple comorbidities with a potentially nephrotoxic medication? The answer is no, unless the goal is to insure categorical antibiotic resistance.

Over the past month I have had some very challenging patients. I will often question, why and how did someone end up here at the correctional facility? I believe it is better I do not know. Actually, it is none of my business; it keeps the care unbiased and pure and it does not impact how I treat them. If one of the inmates upsets the correction officer (CO) or even the nurse for that matter, they have access to a program called JMS, which stands for Jail Management Systems. I thankfully do not have that program on my computer, but that program lets anyone with a password have access to the mug shot and the crime.

Do you recall how it is politically incorrect to say, "I am taking care of the pneumonia patient in room 203." Well, that is what staff will say at the jail, such as, "The prostitute is back," or, "The heroine abuser has returned," or worse! I also have seen staff (COs and nurses) bring up the pictures of the inmates and remark on their mug shots.

There are some interesting individuals at the jail. One is a 24-year-old female who is mentally challenged, legally blind, obese and lives in a group home. She is one of my chronic care patients; she has type 2 diabetes, hypertension and newly diagnosed hypothyroidism. "Theresa" (not her real name) is very sweet; when I met her, she was escorted by one of the female guards. I introduced myself to her and from there on out, I was Miss Beverly.

The curiosity got the better of me - I had to know why she was there. I asked one of the nurses, who is very caring, and she told me: Theresa became disruptive over a promise that was made to her. She was told she would get a snack and the promise was withdrawn and she took the snack herself. She was arrested for disruptive/unruly behavior to staff and another resident at the group home. Prior to me seeing Theresa, she was housed in our medical unit to keep an eye on her. My lovely collaborative physician eventually had her moved to general population.

When I saw her, she was scared stating, "I think I am going to die." Well, that's not good; she had also gained almost 10 pounds in fluid. I moved her back to medical, and put in place orders to weigh her daily, give her Lasix, compression socks and lab work. Afterwards she asked, "Can I have a treat?" Here is the problem: I created a little monster! Knowing she did not have any money on her books, for the next three days I would give her healthy snacks and every day she would ask for me. Uh-oh!

Every day and at least (no kidding) five times per day she would ask for me. I told the Cos to tell her I was not there; I could walk right past her if she was waiting for her blood pressure to be measured and she would not see me (remember, she is blind). I know that is bad all the way around, but her numbers were improving and she was beginning to lose the water weight. She did however catch me once while I was seeing a patient and she walked into my office (diabetes testing is adjacent to my office). I politely informed her that I could not see her. She of course understood. One week later , I am happy to report she served her time and she was released. No more hiding!

I was going to write a blog about neuro-syphilis because I just recently treated a 29-year-old patient for this condition, however, on reflection it seems more apt to discuss the enormous financial costs associated with her care. That being said, neuro-syphilis is a tricky diagnosis; I advise clinicians to read up on it.

Syphilis is commonly referred to as the great imitator. In the case of my patient, she presented with symptoms of meningitis. As we began to peel back the layers of her presentation, we had to consider various etiologies to explain, understand and ultimately treat her persistent meningeal irritation. Bacterial? Viral? Was this a vascular problem? All of these considerations necessitated corresponding tests and extensive lab work, not to mention specialist evaluations (including us - the ID folks - as well as neurology) and a lot of antibiotics.

She spent nearly three straight weeks in the hospital. That is costly for any person, but she was without healthcare insurance coverage. Her condition mandated treatment; failure to do so could have caused irreparable cerebral damage and possibly death. Nonetheless, I cringe to think of the cost of her care and the tidal wave of bills destined for her door. Likely the hospital will absorb some of these costs, but that seems like a totally inadequate solution. There has to be a better way.

I wonder how many other providers, new and old, find they are influenced by the cost of providing care to their patients. Is it best to restrict the quantity of tests in attempts to spare the patient financial ruin? In the age of CYA practice, should cost be relegated to the lowest rung of consideration, financial health be damned?  

It's ironic that I wrote my last post on October 15, 2012, the 1-year anniversary of my one and only job as an NP.

What a year! Or, rather, what a year and a half! The worst of times, yes (the end of a 30-year marriage in June 2011), but also the very best of times (Duke MSN/FNP in May 2011, certification in September 2011, dream job in October 2011), and everyday a new adventure of the heart and mind since!

As noted in a previous post, I've been remiss in submitting posts due to time constraints. With each new experience I'd think "This is a good topic for the blog," but had little time to think it, feel it, or write it. So many patient stories - still mainly uninsured, being seen on the MAP program ($5 paid by the patient, $67 by the grant), in for establishing care with jaw-dropping blood pressures and blood sugars. Everyday a new condition presents itself - reflex sympathetic dystrophy; fibromyalgia; pityriasis alba or rosea, and a host of other dermatologic conditions; ophthalmic herpes zoster; pancreatitis; cholecystitis; absence seizures; iliotibial band syndrome; asymptomatic enlargement of clavicle (more common than one would think). And despite not being the most dexterous of individuals, I now average 20 to 25 Paps a week, and am certified in IUD/Nexplanon insertions, with colposcopic exams to follow.

It has been a busy, fulfilling year professionally, and quite a fulfilling one personally as well. Clichés are often truisms, and as one door closed, another one indeed opened. I am as happy as I have ever been!

Now, the dreaded "there are so many people to thank!"

Thank you, Bev and Sam, for your inspiring companionship in the blogosphere. Last but not least, my deepest gratitude to the faithful readers of our blogs for your always encouraging, thoughtful and insightful comments. You were often the one bright spot in a long, hard day! I wish you all every success and happiness, and a lifetime of fair winds and following seas.

There was a disturbing incident that occurred a few weeks ago. I also look at this experience as an eye-opener for me. I have long come to this realization, but it was never more evident than when the incident happened. First, let me start off by stating, prior to my opportunity to work in corrections, I was judgmental and biased and I thought very little of the people incarcerated. I said and thought some very harsh things. Now, working in this environment, I am glad I am here because I find it rewarding every day.

Now the incident: My health service administrator came to me about a grievance that was filed against medical; she found it valid and asked if I would see this young lady. When I spoke to the young lady, Ms. J., I found her to be very sweet, soft spoken and apologetic for having filed the grievance; she felt the medications she normally would receive were inadvertently left off of her medication list. Ms. J., I found out, has a movement disorder, which was diagnosed according to her as a pseudo seizure. This young lady had been to the emergency room numerous times, had seen a neurologist at our local university, and finally went to Cleveland Clinic, where the recommendation was to consider a neurostimulator to help control her "seizure-like" activity.

I must admit, I was not familiar with a movement disorder, but the way she described her history, I had no reason not to believe her. I placed her on the medications she stated she takes at home, and for the medications we did not have, I allowed her to call her family to bring in her medication (she takes Zofran sublingual; we do not have this on our formulary). In order to prevent the muscle spasms and seizure-like activity from occurring or reducing the incidence, I put in place a clear care plan of the medications she was to have. One of them was Ativan intramuscularly.

Here is the disturbing part: every day after I implemented her medication regimen wuth Ativan, the nurses would say, "She is faking! She has a seizure every day at the same time!" "She is drug-seeking. She just wants the Ativan shot!" I was very upset by this; I thought, who in the heck do these people think they are! For Ms. J., stress, I believed, was bringing this on. The next day Ms. J. asked to see me. She proceeded to tell me how mean the nurses would treat her, and as she was telling me about the occurrence, she went into this spasm where her neck had the appearance of torticollis, and her mouth became very distorted with spasms. Her left arm and leg would contract and she would have very small tonic-clonic movements. She could still speak (not well) and hear, but she was struggling. It lasted over thirty minutes.

I consulted the mental health physician whom was very supportive (my collaborative had called in sick...again!). I tried to tell him what was going on, and I was crying! I felt so helpless, and here are these ignorant nurses (I am sorry audience)...you cannot fake this...who would say mean things every day about her when she could still hear them. She would tell me every day the things they would say. And they call themselves professionals. Even the corrections officers were more caring towards Ms. J. when she would have an episode; even they had a plan in place if she would have an attack.

I am happy to report two things: her exacerbations/episodes have decreased since we put the medication regimen in place, and she is scheduled for release in three days! That entire experience was an eye-opener for me. I tell the nurses, let's leave the corrections and discipline to the correction officers, and judges. I am not here to judge.

I was before, but now I am an even greater advocate of the pill box. Every patient with a lackluster memory, or taking multiple medications, or time sensitive medications should own one. There is nothing better than a physical reminder to keep a body on track.

I was recently confronted with an HIV positive patient on a cocktail of anti-retroviral drugs that routinely forgot to take them or sometimes would take them all twice in one day because they would forget if they had taken them. Needless to say this is a bad habit...especially when the drugs you take are both life saving and highly toxic if taken incorrectly.

Hence the brilliance of the pill box. I like to think of it as a classic NP solution: inexpensive and efficient. Pillboxes are super cheap, but oftentimes if the clinic is open to pharmaceutical reps, it doesn't hurt to ask the reps if they can schick you some. As I grow, ever so slowly into my practice, I have come to realize that logistics are an integral part of my role.

True friendship is a tremendous responsibility, a responsibility that I do not take lightly. My best friend has wanted to return to school for many years to pursue her master's in education, but due to life (married with children, work, financial) she postponed it until now. She states she has never been a good writer and looked to me for help. While I want to return to school to obtain another degree, I have found myself literally back in school helping her. I am not complaining; it feels very good to help someone and introduce them to the world of an advance degree.

So for the next ten weeks we will be meeting to collaborate on writing papers, posting assignments and challenge fellow students' postings on blackboard. Online education is new to my friend but I really enjoy the virtual connection you can develop with a variety of nurse professionals. On September 11, 2012 we met at the McDonald's to talk about a paper on nursing theory until they kicked us out! This may sound strange, but it was so much fun having the paper come together; we were high fiving each other and laughing because the words flowed, and I could not be more happy for her because one week prior she was doubting her decision and considering quitting.

So the cheerleader in me had to route her on. I truly believe if I can do it anyone can, it just takes the commitment, determination, goal setting and visualization of the prize. I decided to share this with my collaborating physician and I may have stated it like, "Yeah, my girlfriend needs help with writing papers, I guess I am back in school." His comment was, "Sometimes you just have to tell people no."

Really?! I do not think so; his words left a bad taste in my mouth. How meaningful is my education if I do not help someone who needs me. I am so glad when I needed help in school, I was not told no. There are many nurses who have the drive, knowledge and expertise but not the degree they need to advance, and if I can bring someone along I am very willing to do it. My friend was very concerned about the online community and mastering all that it has to offer. I told her in no time you will be a pro, and it just takes time and patience.

So as we enter into week two, she is getting responses and she is accusing students of "stealing her comments and articles" and twisting them around (to me) and she is having anxiety again, so the cheerleader directed her on constructive discussions and thoughtful responses. That is how you obtain a healthy dialogue; that is what makes us nurse scientists and professionals. Sigh...eight more weeks to go.

Lately it seems a rash (no pun intended) of patients have asked me how it was that they contracted their Staph infections. Some had MRSA, others MSSA. Some suffered from bacteremia, others osteomyelitis, and others still were challenged by skin/soft tissue infections in the form of painful and unsightly abscesses. Some had recently undergone surgical procedures, some have a history of IV drug use, and others had not set foot in a medical facility in years - which is to say, they didn't have any recent, relevant past medical history that correlated well with their current diagnoses.

Where to begin? Or better yet, how to answer an unanswerable question? With the exception of the IV drug user, it is impossible to say with 100% certainty where and how patients contracted their infections. This is both a tough pill to swallow and dispense.

In the event that they have recently undergone a surgical procedure, likely the infection is the consequence of that procedure, or it was most certainly conducive to its presence. When I inform the patient of this reality it is as if they have never, ever heard of any risks associated with surgery. The follow-up question almost always goes something like this:

"So I got this infection in the O.R.?"

To which I must answer, "I have no idea, and likely we will never know, but infections are definitely a risk associated with surgery."

"So if I never had surgery then I wouldn't have this infection?"

"Again, we will never know, but any time there is a perturbation of the skin, like when a scalpel makes an incision, you run the risk of introducing bacteria that exists on top of the skin inside the body and this can cause various types of infection."

Trying to explain the phenomenon of colonization is cause for even greater consternation. Thank goodness for the CDC. I often solicit the website's patient information; why reinvent the wheel?

But moving forward, I do find that one common denominator and subsequent risk factor for infections is uncontrolled diabetes mellitus. This commonality is something that makes my inner primary/preventative care provider's heart beat faster. I eagerly champion this detail because it provides the patient with some kind of concrete information and affords me the opportunity to engage in some good old fashioned patient teaching.

While I never say that any infection is the direct consequence of a patient's diabetes, I refuse to overlook its contributions. Ultimately, if delivered kindly and intelligibly, this connect the dot exercise is empowering and illustrative. An NP should never pass up the opportunity to practice health promotion; it's what makes us great.

"America has spoken" says Nick Cannon from America's Got Talent and the winner is: The American People! This is the feeling of many when the Supreme Court ruled that the Patient Protection and Affordable Care Act (PPACA) is constitutional. Are the American people really winners? Absolutely!

As the healthcare reform unfolds, nurse practitioners are poised to meet the challenges of emphasizing health promotion, disease prevention and effectively managing chronic disease. Approximately 80% of nurse practitioners provide primary care services by delivering the highest quality, cost-effective treatments to the population.

This also means more creative job opportunities for nurse practitioners and physician associates alike. The PPACA offers an increase in development of nurse practitioner recruitment and incentive programs addressing the shortage of primary care providers. Hopefully this act will result in less over-usage of the emergency departments and more responsible use of primary care providers and clinics.

Working as a nurse practitioner in an Ohio correctional facility, these individuals abuse the system. The goal while people are incarcerated is to educate, teach responsibility, and when they are scheduled for release, provide clinic appointments and prescriptions.

With the passage of this bill, nurse practitioners will receive better reimbursement by Medicare and Medicaid, and an increase in prescriptive authority, especially since the passage of Schedule II prescribing; SB-83 was recently approved in Ohio by Governor Kasich. Yes, everyone wins when everyone has access to care.

My contact with pain patients was extensive during my residency in Aurora, North Carolina, a coastal town of about 400, with a patient population compromising of retirees, commercial fisherman and above-ground miners from a phosphate mine. I knew from that experience that even if I never found a job as an NP, I would not choose to do pain management. Of course, pain management is an invaluable specialty, but in its practice a few bad apples spoil the whole cart. So much unproductive time is necessary with these patients, who are tangential by necessity (talking around what they really want) and, well, manipulative (getting me to give them what they want).

Since I started my job as a new NP at the health department, I've had many "establishing care" patients whose chief complaint is "pain." The usual outcome of such visits is that what I can offer for pain syndromes - NSAIDs, muscle relaxants, tramadol, and/or gabepentin if there is a nerve component - are inefficacious. When questioned what had helped in the past, the answer would be one of the opiates. In many instances, all the non-narcotic pain medications are listed among "allergies/intolerances."

The saving grace at moments like this is to inform these patients of the "No Narcotics" policy instituted by an MD who was three providers before me in the last 2 years. It's probably obvious in the small community that I serve -- word gets out that there's a new provider in town who may not have heard their stories before. They have no way of knowing, of course, that the state's substance reporting system contains information on every controlled substance prescribed for and filled by a patient with a mere entry of a name and date of birth. We also request prior medical records from one of the 5 primary care providers in the district and oftentimes these same patients have been fired from their practices for abusing pain medications.

For those with insurance, a local surgeon whose practice is a bit slow offered to take on my pain patients, although even he has stopped his open door policy and will now review a patient's chart, and even conduct a personal interview, before he will take one on. He has turned down three of my referrals in the last 2 weeks. He has obviously discovered that even with a pay source it's not easy money.

Despite it all, during these "establishing care" visits, I do manage to divert their attention long enough to discuss preventative care, and the free programs and discounted labs offered by the health department. Surprisingly, many of these patients, both male and female (males predominate), have remained with me for their primary care. In fact, my nurses tell me that I see many more male patients than any of the previous providers had seen.

If I'm sounding a bit cynical I don't mean to be. It'll be 1 year into my job and I still wake up every morning feeling that I'm the luckiest girl in the world. I do feel "old before my time" in terms of my NP-hood, but in a very good way!

I don't know how many of my fellow NPs and PAs have seen and or heard about HBO's four-part documentary on obesity in America, The Weight of the Nation, but I can't recommend it enough: it is an awesome and totally relevant examination of health in the States.

So many of the individuals profiled in this series were reminiscent of patients whom I have treated for various infections complicated by their obesity and corresponding chronic illnesses, namely diabetes mellitus and hypertension. The series thoughtfully, dare I say poetically, illustrates the interconnectedness of disease states, infections and obesity.

I am confident that most of the information presented in this documentary is not new, nor novel to many of the NPs and PAs who choose to watch it, however, the startling extent of the problem may compel you to initiate more conversations about weight loss and lifestyle changes with your patients, irrespective of your specialty or practice. 

While I appreciate that a documentary on HBO is not tantamount to staying up-to-date on scholastic research via journals and conferences, trust me when I tell you that this documentary showcases the talent. Most of the experts interviewed for this series preside over some of the most elite research institutions this side of the Atlantic. So it's not like watching the dumbed down Hollywood version of an excellent novel, rather it's like watching the authors read their books aloud.

Costs for healthcare are rising. There is not a revelation in this statement, but as providers, we have to be mindful of the dollars we use because it affects raises. My former mentor would drive that home for me. When I would order a test, she would ask, "Will that test change your treatment plan?" And if I responded with "no" then she would state, "Don't waste the dollars."

She would follow with, "I am trying to get a CT machine for the facility." It would be nice, but it will never happen. Diagnostic imaging (CXR) has been sufficient and if advance imaging was recommended from the radiologist, the individual would go to our area hospital for further testing. But again, if the treatment plan is the same most likely the individual is not going anywhere. Do you ever feel like you are part MacGyver, Houdini, and Professor Gadget?

 I have said all this to describe a thought I had while caring for an individual who had used toilet paper to clean his ears, and now cannot hear. He admitted to cleaning his ears with toilet paper and the end of a pencil stating, "I think the toilet paper is stuck in there." Without an otoscope, I could see the foreign body in both ears and it was hard as a rock! So I decided to make a mixture of liquid Colace and Debrox and instilled into his ear canals and let him sit for 30 minutes.

After the time had elapsed, I flushed his ears with warm water and hydrogen peroxide. I thought of all the creative things we as nurses, NPs and PAs have used to save on cost, time and just to downright get the job done. For Example, Colace, the stool softener, really works to not only soften fecal material, but cerumen, paper, and erasers from pencils. I have used Metamucil for not only a fiber supplement to bulk one's bowel movements, but I have also given it to my patients as a gentle facial scrub for those individuals with acne.

Selsun Blue, the shampoo, is a wonderful mild body wash for individuals with dermatologic issues. Toothpaste has been used for acne pustules. The condiment mayonnaise was used recently for a lice outbreak we had in the pregnant population. Calcium carbonate/Tums has been used for a vitamin supplement in those who do not drink milk, and in this population they are indoors and they do not get any sun exposure. Tongue depressors are used for splinting fingers, and topiramate for weight loss and when the individual states they have migraine headaches.

Even though I do not condone this behavior, individuals have used the end of a pencil eraser for ear plugs, hence the problem at the beginning of my blog. I have even used suture material to lace a cracked plastic slipper; they were not on suicide watch. If there is anything you used in the clinical setting where you repurposed a treatment or item to help with costs, will you share it with me please? I love MacGyver!