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First Year NP

The Waiting Game
December 8, 2014 1:54 PM by Fawn Workman

December 2nd. It is currently 2:20 pm, one day after when we were told we would find out who got into the second fellowship I applied to and interviewed for. The date changed at least once - at first we were told we would know by the Monday before Thanksgiving, and then it was changed to December 1st. This is the fellowship I interviewed for the day before I took (and passed!) my boards.

I called and was told that the secretary is still making calls. I don't know what to think. The day has slipped by, and I'm trying to not let my mind wander back to whether I made it or not. I reason that maybe they are going in alphabetical order, and I am at the end. But deep down I think that I didn't make the cut.

What if I did get in? It would be less pay than a new grad NP, but a great experience: living in a new city, learning new procedures and intensive experiential learning sessions - just up my alley. Although I learned a lot in graduate school, I want to learn more deeply in real life.

And what if I didn't get it? My friend Alicia texted, "Then that means there is something better for you out there."

Another person who interviewed the same day for the same track texted me at 5:30 pm. He got in. Still, no call for me. I congratulated him. "Thanks. Hope it works out," he said. "Me too," I thought.

December 3rd. 1:30 pm. I called and reached another one of the secretaries. I remember she commented my essay was great. I asked when we would know, and she said that the letters would be sent out this week. "So, if we got a call, we were accepted; and if we get a letter, we were not accepted?" I asked. "Yes, that's correct," she replied.


I really thought this interview went well, and I liked the people and the area. I was really excited about the possibility of a fellowship. I wonder if it is something about me, something I said, or did, or didn't do.

Rejection hurts. I web-searched a list of famous people who failed or were rejected time and time again early in their careers. The list includes Sir Isaac Newtown, Walt Disney, Lucille Ball, Winston Churchill, Thomas Edison, Van Gogh, Dr Seuss, Steven Spielberg and many more. They didn't find their calling, or didn't have others see in them what they knew deep down, but they never stopped. They pushed on.

I know that there are only so many available openings for a position. There is a chance I'm on the wait list, but the waiting game is over. At least now I know, and can move on. My former instructors and preceptors have faith in me and my abilities. I have several areas of interest that I will continue to seek. There are many bright possibilities in my future, and like my friends and family say, "something better is headed your way!"

Boards & A Second Interview
November 24, 2014 12:04 PM by Fawn Workman

I'm not sure how to describe my experience of taking national boards. Maybe I should just explain. This is by no means my endorsement of my methods. For one thing, I'd recommend more study time.

I passed a predictor exam about a year ago. After passing my school's comps, I listened to review courses CDs as I drove, and spent some time in my review and quiz books. But I didn't do a live review course, or spend several weeks studying. I signed up to take boards several weeks before I finally received my authorization to test (ATT). There were some good available dates in my city. I waited a week, then I searched for my city's availability again, and all of a sudden, there was nothing that worked for me. I searched other nearby cities, and available dates started to disappear like crazy.

Out of desperation, I looked at the distant city where my next (second) job interview would be in two days. There was a date available, the day after my big interview. So I took another predictor exam, and I passed with a good margin. I felt fairly confident, so I signed up to test.

And so began the marathon of studying.

My interview went well, I think (and I hope they think so too!). I enjoyed the process much more than my first job interview. Perhaps that comes from just being my first interview as an NP. This organization had very nice people, their Advanced Practice Providers initiative was innovative and encouraged NPs to work at the fullest scope of their practice. I felt very comfortable there, despite the following things: 1) Having boards looming over me the very next day, and 2) Being in the middle of a big interview, and 3) During a break, I checked my email and found out I didn't get the job from the first interview. I thank God for giving me such peace through everything that happened that day.

The next day, I arrived at Prometric early and a bit anxious. I immediately wrote down all sorts of things I might have a hard time remembering. Then I went to start the test... and my mouse didn't work. I was re-set up on another computer. Some questions were really, really tough. But a well-known review course leader told me "don't expect the test questions to look like anything you've ever seen." And she was right. I kept as calm as I could, and tried to consider each question carefully. I felt mentally beat up by the end. After reviewing about 20 of the ones I flagged, something in me just said ok, you've either got this or you don't. So I hit enter.

And I waited.

The next screen was a survey - are you kidding me? All I really wanted was to know if I passed or failed! I did the survey anyway. Then it came up: preliminary results show you have PASSED. Passed!!!! Oh, happy day!

Celebrating NP Week!
November 10, 2014 1:16 PM by Fawn Workman

Nurse Practitioner Week is November 9-15, 2014 and as of 2014, there are more than 192,000 NPs in the US. That's up from 140,000 in 2010 - a huge jump that is expected to rise to 244,000 by 2025!

Since I first entered my master's NP program, I have been involved with my local chapter of the Virginia Council of Nurse Practitioners. I have had so many positive experiences with this fine group of NP leaders! Their support and encouragement have really helped my transition from RN to NP student to new NP. While I love being a small part of the AANP at the national level, and the Virginia Council of Nurse Practitioners at the state level, it is this local chapter environment that is so very important to me. Through this organization I have learned about legislation that may affect NP practice, advocacy, changes in billing and coding, new drugs/ drug updates, local treatment options for certain conditions, and the list goes on.

Every year, we participate in NP Week. Usually we have one of the local governments sign a proclamation of NP Week, and we always have some sort of community involvement - in years past it has been collecting books for underserved kids and highlighting our free clinic NP volunteers. This year, we plan to raise money for local cancer patients' needs.

Awareness and change starts locally and grows. There are a hundred small ways you can be proactive in celebrating NP Week! You don't have to do anything huge (no bullhorns and clashing cymbals required!), so here are a few small ways you can join in the fun.

  1. First, thank an NP who helped get you where you are today!
  2. Display some NP facts in your reception area.
  3. Send a letter or press release to the PR person or CEO of your organization, highlighting some of the specific ways you and your NP colleagues are making a difference in your workplace and community (see the AANP [2014c] tool kit).
  4. Perhaps you can meet up with your local NP association and team together on a project to highlight NP week or volunteering in your community.
  5. Call your legislators, let them know it is NP Week, and thank them for their support on some recent matter that positively affects your practice and patient care.
  6. Social media is a great tool too, and remember to always use professional common sense and etiquette when sharing!

So, how are YOU celebrating NP Week?

I hope you have found a local NP organization to become a part of- and if not, find yours today! The AANP (2014a) can help you find your regional and state organizations. Here's a link to get you started: http://www.aanp.org/about-aanp/regions

Here's a great resource for sharing NP week with the public and your organization! http://www.aanp.org/all-about-nps/np-week


American Association of Nurse Practitioners (2014a). About AANP- Regions. Retrieved from http://www.aanp.org/about-aanp/regions.

American Association of Nurse Practitioners (2014b). Historical timeline. Retrieved from http://www.aanp.org/all-about-nps/historical-timeline.

American Association of Nurse Practitioners (2014c). NP week. Retrieved from http://www.aanp.org/all-about-nps/np-week

Just Breathe
October 31, 2014 3:55 PM by Fawn Workman

I'm Fawn Workman and I am a brand new MSN graduate. I'm so new that I'm still waiting for a test date for my FNP boards! I'm glad you have come to read about my thoughts and musings on my first year as an NP.

Since April, I have logged several thousand miles driving for clinical in another state while living with family members. I've also flown to Nashville for the AANP conference, to Kentucky for my school's diversity weekend and to Oregon for an externship at the Indian Health Service. I am really thankful I had these awesome opportunities, but all this busyness can create unseen muscle tension.

I once watched a Physical Therapist demonstrate the relaxation of muscles with simple deep ‘belly' diaphragmatic breathing while the participant was hooked to a machine. It was amazing to see the release of so much tension with a few deep breaths.

So I decided to splurge and take a graduation celebration trip to Hawaii.

Ahhh... It was so nice to just breathe, to sit back with one of my BFFs and take in the warm, soft sand between my toes, smell the salty air of the most beautiful ocean, to just relax and have fun. I thought about sacrificing some of my school materials to the volcano, but unfortunately there aren't any active volcanoes on Oahu.

I didn't want to leave Hawaii. After about 16 hours of air travel (seated near every misbehaving child or crying baby), reality - with all its to-do lists - waited for me on that tarmac. Plus a few extra surprises.

Maybe all that yoga and Lamaze breathing works, after all...

I graduate this weekend. When I walk across that stage, everything I have worked for these many years culminates in that moment: all the blood, sweat, tears, friendships, heartaches and triumphs of the past three years. I want to run up to my friends and shout, "We did it!" It will be awesome to hug mentors and instructors. I hope my family enjoys the weekend and see all the things I want them to experience in a short amount of time. After getting back this weekend from the six-hour trip, I will immediately have my first NP interview. (YAY!) But, no stress, right?

What was that I said about breathing? Oh, yes, Fawn. Don't forget to breathe! Be thankful, pray, and enjoy every bit of this weekend-every crazy, wonderful, exciting moment of it. Inhale, and exhale. And smile!

So, tell me, how do you relax? Are you a student just trying to make it through the next paper, or a new NP trying to make it through the next day? Remember, every day is a gift. Hug someone you love, have a cup of tea and breathe! And maybe get a massage too! ;)

And Then There Were None
September 22, 2014 12:41 PM by Katrin Moskowitz

One year ago I was offered the wonderful opportunity to blog for ADVANCE for NPs & PAs. I was unsure if I would be able to provide any words that would be beneficial to the community, as I was having a hard time even thinking of myself as a practitioner. One year later, many things have changed.

I enjoy going to work every single day. The challenges and learning opportunities continue to occur on a daily basis and I feel that my knowledge base is ever expanding. Over time, I have built relationships with new co-workers and have discovered how to delegate, consult and make decisions. There are many areas that I would like to continue to develop, including EKG interpretation, x-ray interpretation and complex wound repair.

The patients have been very receptive to my new role and have been a pleasure to work with. I continue to love working with the various age groups throughout the day, as it keeps my mind fresh and adaptable. Are there interesting patients along the way that make you think on your feet, or just shake your head? Sure, but in the end, they leave you with a better understanding and an increased point of view.

I continue to progress in my Doctorate of Nursing Practice program at Frontier Nursing University. It has been a challenge, but one that has been accomplished in baby steps. If I had to choose again, I am not sure that I would have jumped on board in the program so soon after graduating from the FNP program. There is a lot to be said about gaining clinical experience in order to choose a capstone project that one is passionate about. The faculty has been supportive and has provided positive criticism in order to develop myself as a doctoral student.

The greatest lessons I have learned over the past year are to be open to change, adaptable and continue to be compassionate. Challenges will always arise; embrace them, solve them, and learn from them. Do not be afraid to ask for help whether from fellow practitioners or support staff. Love what you do, if you do not, then don't do it. Last but not least, I have learned that I need to take care of myself. Heading back to the gym and adjusting my nutrition has made me feel that I can be proactive and speak to my patients from personal experience. Do not ask a patient to do what you are not willing to do yourself.

Thank you for allowing me to share my journey. Buckle up and pave your own way, be ready for bumps in the road and most importantly: Enjoy the scenery!

A Wolf in Sheep's Clothing
September 8, 2014 10:54 AM by Katrin Moskowitz

My experiences with patients have been very positive since I have come into practice. Most are able to communicate their complaints effectively and some may even tell you exactly what antibiotic they want, or what they believe their diagnosis to be. On occasion they may ask for things that are clinically inappropriate and at times may make my eyebrows rise.

In the state of Connecticut, nurse practitioners are able to prescribe schedule three medications. This can be a double-edged sword. In the setting of urgent and emergency care, there tends to be more prescribing of controlled medication that occurs due to the nature illness and injuries. I consider myself an appropriate prescriber, but have to make sure that I listen to that "inner voice" when situations and circumstances do not add up. As prescribers in CT, we also have an online database that we can utilize to see how many controlled medications a patient has been filling. This has been very helpful in order to verify or disprove my suspicions.

I will be honest: I do not like when patients openly lie to me or try to pull a fast one. Who does? Just recently I had a patient who truly tested my patience.

She was a 50-year-old female who came into urgent care as a self pay patient for back pain. She stated to the medical assistant that she tried to get into her PCP that morning, but that they were full and would not prescribe anything unless he was physically seen by a provider. She was due to start physical therapy the following week and did make an appt with her PCP in 2 weeks. The MA asked that I look her up in the database as she was acting suspiciously. She had had several months of narcotic pain medication prescriptions, but had a documented case of a severe staph infection that required multiple skin grafts. I went in to evaluate her and diagnosis her with back pain with sciatica. The patient was told that in no way would she be prescribed long term pain medication in this setting and I would prescribe her medication to last through the weekend (her visit was on a Friday). I also wrote a letter to her PCP stating that I saw her and the plan of care and the need for them to follow up with her. The next day she calls asking if I would increase the dosage of her pain medication and she was told no. I was off for the weekend and she ended up coming back and telling another prescriber the pain medication was too strong and that she needed a different lower strength narcotic. The per diem prescriber changed her prescription. On Monday she came in again asking for a "less strong" pain medication. Unfortunately for her, I was back and knew what she was attempting. I brought her into the room and told her that she needed to follow up with her PCP and that she would no longer receive controlled medications from this facility again due to her dishonesty. In her last ditch attempt she asked me if I could "give her a few Tylenol # 3" to get her through.

I was angry - really angry - and needed to remove myself from the room. Maybe I am still naïve and think that patients all have good intentions, but these patients make me rethink this notion. I know that I need to keep myself neutral as not every patient ends up being a wolf in sheep's clothing.

Those little things
August 25, 2014 12:53 PM by Katrin Moskowitz

There are days in practice that the hours go by without you realizing it. Patients are in and out quickly, you work hard to complete your charting and tasks become second nature. Then, certain patients come in and make you smile with the things that they say, the mannerisms they exhibit or the way they look at you. Children are the most honest, and how they see the world is eye-opening.

This week I learned about volcanoes, silly sticks that cause toe injuries and worries about "ouchies." In the world of urgent care and the ER, children often are most afraid of things that will cause them pain. I have been very fortunate that I have never (I am knocking on wood at this moment) to now have to swaddle or restrain any child prior to suturing. I will give most of the credit to the wonderful medication LET, however I also would like to give some credit to my approach with the smallest of patients.

Recently I have found that asking what the patient is most afraid of helps to get that fear directly out of the way. Of course, this can be applied to the older children and adults of this world, as well. I have also found that kids are often frightened by my suture tray and all of the scary, shiny instruments it contains. I now compare myself to Bob the Builder. I tell the kids that while Bob fixes things, I fix people, and that I would be coming in with my people-fixer tools. Because I often have extra hemostats that I end up not using, my little patients get to hold a pair to see what they feel like.

The relationship that I build with the kids rubs off on the anxious parents, and often the whole family leaves not only fixed, but happy and relieved that their visit was much less traumatic than anyone had anticipated. The visit often ends with a nice sticker (and a sigh of relief from me).           

A patient said to me today, "You don't just hear me, you actually listen." This makes my heart feel good all around.

It's Not Always About the Medicine
August 12, 2014 8:44 AM by Katrin Moskowitz
From August 3-8, I went away to Boy Scout Camp to work as the nurse for the week. This is the first year we have been involved in the organization with my six year old son and the first year that we decided to send him away to resident camp. The mom in me decided that there was no better way to be watchful than to be on the same property as him, but to give him space to grow and learn amongst his peers.

As a professional, it took me out of the hustle and bustle of electronic records, x-ray machines and telephones. It took me into nature, amongst hundreds of excited children, and back to tender loving care, Band-Aids and high fives. It reminded me that no matter where you are in medicine, it is not always about that. It is being holistic, knowing where your patient is coming from and how to make them feel better right in that moment. As a person, it has allowed me to be calm, creative and centered.

This too ends and the real world of medicine awaits me yet again. But I return refreshed and more understanding for individuals. I hope that the kids and adults alike enjoyed their time here at camp, and if they had to come visit me, at least left with a smile.

I reminisced at the fact that almost a year ago I was finishing my clinicals and was on my way to starting a new, exciting career. It is truly hard to believe that time has gone by so quickly but am excited to find out what year two has in store for me. There are definite professional hopes that I have, and I believe that you truly can never stop learning.

The kids at camp taught me how to be a caring provider while showing me the joys of GAGA ball, whittling, songs and dance, and outdoor life. Thank you, Camp Workoeman!! Do not ever doubt yourself; remember where you have come from and where you can go with your profession as an APRN. If you are on the journey of getting there, keep going, don't stop and never look back!



NP's Orders
July 28, 2014 10:53 AM by Katrin Moskowitz

There are not many things that frustrate me in my clinical practice. Most patients are open, receptive and leave shaking their heads in agreement to your plan of care. What happens once they leave your office is often unknown. You hope that they venture directly to the pharmacy, take their medications as prescribed and their health improves.

What I am occasionally finding is that my hope of 100% patient compliance is just a dream that I have comprised in my own mind. As a new practitioner, I really focus on patient education: informing them of the expected course of illness, how to take the medications, possible side effects of those medications and, of course, things to be concerned about.

In our urgent care, we encourage patients to come back for rechecks for common procedures such as suture placements and incision and drainages - we want to make sure things are improving as expected.  I am amazed at how many patients decide that they do not need to start their prescribed medications because they thought that "things will get better on their own." This in turn leads to worsening conditions, longer recoveries and frustrations on both the patients' and practitioners' parts. Is there an answer to this commonplace problem? Maybe I should be more firm when going over prescriptions, repeating the importance of taking medications as prescribed.

My hours in primary care, as limited as they are, have been quite successful. All of my patients who have come in have completed their blood work and have made improvements with lifestyle changes and follow ups. I enjoy showing patients how they can make simple changes that can last them a lifetime. I know our instructors said we may not be able to change the world but I hope to at least impact one person at a time. My success streak in primary care may be short-lived but I will enjoy it while it lasts.

Keeping It Interesting
July 14, 2014 9:35 AM by Katrin Moskowitz

The last few months have been a balancing act, but one that I am enjoying. In the last two months I have been back in my Emergency Room working as a provider. I have been very fortunate that the staff that I previously worked with as a nurse have accepted me in my new role and continue to work with me in an efficient and professional manner. I was approached by a hospitalist and asked how I was being accepted and was happy to tell her what a wonderful transition it has been. It felt great when she said, "Well you worked so well with them before, I did not expect anything else."

With my new role has come the ability to provide input on departmental issues from two different perspectives and advocating for patients in a whole new way. The ER providers have been wonderful to consult with and they have helped me to grow each shift. No day is the same and my mind is challenged vastly. I have been able to order new modes of testing and I enjoy getting results within an hour (versus twenty four hours in urgent care).

I continue to work through my DNP program. It has not been easy, because, as they say, doctoral studies are a whole different beast. There is so much more in the way of scholarly writing and in-depth reading that I find sometimes hard to find motivation to complete, especially now that the weather is so beautiful. Those are excuses, however, and I just need to sit down and do it! I just think of the end goal: heading to Kentucky as Katrin Moskowitz and returning as Dr. Moskowitz.

My family continues to be very supportive, and without their tolerance for my perpetual need for learning, I would not be where I am today. They do not believe me when I say I am done after my DNP is complete, but I promise that my career as a student will be! In the meantime I just need to organize my calendars, distribute my time and continue forward one day at a time!

Diversity Impact 2014
June 30, 2014 12:03 PM by Katrin Moskowitz

I recently had the opportunity to return to Hyden, Kentucky for their Diversity Impact weekend. This is the second time I have had the privilege to attend and was even more excited to be there as an alumni of Frontier Nursing University.

When I first thought of diversity, my mind automatically jumped to the word minority. I soon found out that diversity can describe both major differences amongst us but can also include the things that we share. Either way, each one of us has the opportunity to bring all of our own diversities to the table in order to learn as both individuals and also as professionals. The weekend included students, both women's health, family and midwifery, graduates and faculty.

The weekend encompassed candid discussions, eye opening exercises and special guests. We had the pleasure of having Kitty Ernst join us who herself worked hand in hand with Mary Breckinridge herself. This woman is a spitfire with a passion for women's health that is indescribable. She reminds me so much of my Oma in Germany and I smile being in her presence.

Mid-weekend we were told that we would be joined by Cristi Turlington Burns. Known for her modeling career she also is an advocate for decreasing maternal and infant death during childbirth around the world. She spoke with us about her organization: Every Mother Counts and showed us video clips about the midwives that were being trained through her fundraising efforts in Haiti. I recommend that you view her documentary: No woman, no cry to understand the plight of birthing women throughout the world.

Being in the mountains of Kentucky allows you to connect with nature, the mission of Frontier Nursing University and humbles you from the soul out. It is always hard to leave as the connections that are made with individuals in such a short amount of time is inspiring. 



To end the weekend the local news station also paid us a visit. Here is a great segment that they were able to put together:

Diversity Impact 2014

Patient Perceptions
June 16, 2014 11:45 AM by Katrin Moskowitz

During my time as an emergency room nurse there was always a level of frustration in regards to what patients perceived as an emergency. I always said, "One person's emergency is not another's." When our fast track area was open between 11 a.m. and 11 p.m., this was less of an issue as you could funnel less acute patients through this specially intended area. The frustration increased, however, when these less emergent patients came after the fast track areas and bogged down the care of the acutely ill. Nevertheless, we took care of everyone, because in their minds they needed to be there.

In urgent care I am seeing a complete opposite of patient perception. Just last week I sent the following two patients directly to the emergency room for further evaluation:

Case 1: 58-year-old male who was shopping at a local grocery store and told his wife he needed to go sit down in the car. The patient developed sudden onset of right lower leg redness and swelling. Has a history of a two week admission 4 years ago for severe cellulitis. When they arrived home the patients temp was 99.8 and one hour later it had spike to 102 with rigors and general feeling of unwell. The redness had increased and the lower portion of the leg now appeared greyish blue.

Case 2: 31 year old female with right lower quadrant abdominal pain that started that morning and continued increasing over the day. This was accompanied by nausea and then the inability to stand up straight. Right-sided lower abdominal rebound tenderness and guarding.

Both of these patients were admitted, case 1 for cellulitis with sepsis and case 2 for appendicitis.

Now I may have the advantage of anticipating or explaining to patients what may be done for them at the ER and I will be honest that I will use it when necessary!

I have also been afforded the opportunity to return to my ER stomping grounds as an APRN per diem. I have already completed some mini-orientation shifts and next week will work my first official 12 hour fast track shift. It feels great to return to my community, and also to work again alongside the staff that I grew to love over the last 7 years. I look forward to increasing my skill sets and fine tuning the ones that I currently have.

Time really is flying by. It still seems surreal that this is my career and this is what I get to do on a daily basis.

Inspiring Primary Care Innovation
May 27, 2014 9:07 AM by Katrin Moskowitz
I recently had the wonderful opportunity to attend the Weitzman Symposium with a focus on primary care. It was hosted by Community Health Center, Inc., and it was held on the beautiful Wesleyan University Campus. The focus was on inspiring primary care innovation. And inspire me it did.

Community Health Center, Inc. (CHC) in Connecticut has a longstanding tradition of implementing new and innovative solutions for its patient population, which is mostly comprised of underinsured, diverse and low-income patients with limited access to specialized care. I will be honest that one reason I did not enter community health directly out of school was the thought that I would be utterly frustrated by the inability to provide the care I felt a patient needed, due to dictation of state insurance. I learned on this day that this is not how it needs to be and that CHC was working hard at changing that thought process.

The day included several wonderful speakers and then a responsive panel from CHC who educated the audience about how they, in their community setting, where implementing the innovative ideas that the speakers had presented.

Thomas Bodenheimer, MD, discussed the pressing issue of the shortage of primary care providers and whether recruiting more providers would make a difference. Instead he encourages centers to "share the care." This means allowing medical assistants and nurses to work at the top of their licenses in order to lower the burden on the providers. Therefore, if providers are not spending most of their time trying to accomplish tasks that others could complete, they could expand their case load. CHC spoke in return on how it has in place standing orders for nurses and medical assistants to be able to manage such things as hypertension medication and diabetic foot checks.

We heard from Aaron Smith, cofounder of the Young Invincibles, who took it upon himself to educate and empower the youth of the country to take control of their healthcare options and who was on the forefront of the move to ensure that young adults are covered under parental health insurance until age 26. Sandra Sarkar, chief of staff at Health Leads, gave an invigorating speech about how her company was taking steps in bridging the socioeconomic barriers to healthcare.

The day taught me to not be afraid of challenges, but instead be a partner in finding innovative solutions.

As Ghandi has said, "Be the change you want to see in the world." For more information on CHC, visit: http://chc1.com

Time Flies When You Are Learning New Things
May 7, 2014 8:04 AM by Katrin Moskowitz
It is hard to believe that I have been in practice for 6 months already. It only seems like yesterday that I sat in front of that ominous computer awaiting my fate. I consider myself very fortunate to have found a position that allowed me to ease into my new role and learn new skills at my own pace. I have been off of orientation since January and continue to love what I do.

Having been an ER nurse for my entire nursing career, I have had to get used to the amount of patients I see who are for the most part healthy. This is especially true for the elderly population that I encounter. I guess my view has been a bit skewed, since I had seen so many elderly patients so sick. Now I have patients over the age of 90 walking in on their own, taking minimal medications and enjoying their lives.

I really enjoy the patient interactions and the variety of my daily schedule. Now that the seasons are changing, so are the common presentations. As the weather has warmed up we are beginning to see the tick bites and poison ivy dermatitises erupt. We continue to see positive influenza results and are beginning to see more orthopedic injuries as children begin jumping on their trampolines and riding their bikes. My favorite procedures still remain suturing, incision and drainage and, funny enough, ear irrigations. Patients are often perplexed as to why I would like to do those things, and I tell them that it has to do with instant satisfaction! There are many times that I send a patient on his or her way with medications that may take days to truly allow them to feel better, but with these procedures we have a resolution right away. Procedures also give me the opportunity to talk to patients for a longer period of time, which is often a nice change to the quick in-an-out mentality.

I also spend 5 hours per week in primary care. This has been a challenge on its own, mainly because a schedule is preset for you. I have had to learn to pinpoint my conversations with patients, preplan my day and delegate in order to stay on point. I do enjoy the ability to follow through with patients when I start them on new medications and build relationships with them over time. My primary care preceptor was instrumental in showing me how I can impact a patient's life in a short amount of time.

I would not change where I am at for anything. I am glad that I made the career choice that I did. Over the next few months I will continue to build my skill sets and hope to gain more knowledge in the areas of x-ray and EKG interpretation. I am continuing with my DNP classes, which has also allowed me to gain new perspectives on what else is going on around the country.

Lastly, I want to give a shout out to all of the people in New York state who worked diligently for passage of legislation that will allow APRNs to practice independently after 3 years of practice. This new law will open the doors for many NPs in the state. I look forward to what this may bring for my own future.

Trusting your gut
April 25, 2014 8:22 AM by Katrin Moskowitz
As a new practitioner there is always that "second guessing yourself complex" that hovers over you like a black cloud. One benefit that I have had is that I have 6 years or ER nursing experience behind me. It allows me to have that gut feeling that tells you something is not quite right. This feeler system has definitely followed me into urgent care. I do rely on others around me to give me second opinions when I just can't put my finger on what is going on. Sometimes, however, this can give you a false sense of security.

Two weeks ago I took care of a 58-year-old woman who had undergone a right hip replacement a few years earlier. She was out and about power walking when she tripped over uneven pavement, falling forward onto her right side. She came to me 2 days later with persistent right sided groin pain. I decided to x-ray her hip to make sure that her prosthesis was in place and that no fractures were present. Now I will be the first to admit that I still have not grown completely comfortable reading x rays. I have only been at it for 4 months and see new films each and every day. I did note a lucency on the acetabulum but was unsure if this may have been an anomaly due to the previous surgery. I decided to call the radiologist in the reading room to get his opinion. After a brief explanation and discussion, I was told that the reading was negative. I felt relieved and spoke with the patient and explained that I spoke with radiology to review the case. I advised her to follow up with her ortho and to use her crutch for assisted weight bearing.

The next day I received a call from radiology about the same patient. Alas, that provider saw a concerning lucency on the film and asked that I bring the patient in for additional films including an oblique view. My heart sank a little. I called the patient back, we completed the oblique view and sure enough there was an obvious fracture on the view. I was relieved to hear that the oblique view is not one normally ordered. In the end the patient still followed up with ortho and it did not change the plan of care. I discussed it with my collaborating doctor. I knew that I had followed correct procedures and that I had handled the interaction with the patient well; the physician agreed.

A lot of what we do in urgent care is trying to take in all that the patient provides us in a very short time. Yes, most of what we decide to do is based on out assessments, but there are times when our senses give us additional information.

This was what I saw about a month ago when a 49-year-old patient came in complaining of nausea and vomiting for one month. He had a multitude of comorbid conditions including liver issues, obesity and GERD. He was due to have an endoscopy in 4 days and his current PCP was unable to see him in the office that week. I did his exam, which was benign, and told him that there were limited things we could do in our setting. I offered to complete some basic blood work on him and to order some medications for nausea and urged him to go through with his endoscopy, since it would mostly likely give reasoning behind his symptoms. The next shift that I worked, I was checking labs and noted that his BUN and creatinine came back at a dangerous level. I quickly looked him up in the hospital system and saw that he had been admitted for renal failure and discharge. I quickly called him to follow up and see how he was doing. He immediately said "Thank you so much, you saved my life". The lab had called him that evening and he promptly went to the ER. Those are the moments when you make decisions based on gut feelings and the payoff is immense.

We as practitioners new and old need to trust our education, our experience and of course, our gut!!!



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