Don't trust my FNP

[KalipsoRed21, BSN, RN]

Not sure how to handle this situation, but the ***** in me is coming out so I thought I should ask for some guidance. I have been a nurse for a decade. I have ER, cardiac, infusion, med Surg, and travel experience. Right now I am doing home health.

My husband got a DVT and some small PEs over a month ago. Started Xeralto. 3 days later the knee in the leg with the DVT got like 3 times the size. Called his MD's office with concern. We see an NP there, never the doctor. It has been the same NP for at least the last 4 years. And I have never really had a problem with her until now...and mostly because we hadn't gone into the office for anything I didn't already know what to do for until now.

Anyway we went in. She didn't think it was anything more than my husband's arthritis. I asked her if I could let him wear a knee brace with the recent dx of DVT and she said she thought it would be fine. I was really not certain of her answer and she did ultimately decide to have the doctor come look at it. The doctor tried to aspirate fluid but was unable to. Then the doctor said he should do any compression to the leg due to the DVT. That he was going to send us home with antibiotics and something for the inflammation. He then turned to the NO and said what drug can we use that is not an NSAID. Her response was ibuprofen. I was like how about a steroid? Now I was really willing to shake that off as being caught off guard...I've done that too. They also ordered CBC, BMP in a week. But a week later after the steroids ran out my husband's condition deteriorated rapidly. Increased pain in the joint, poor appetite, fatigue. So I called the office and they got a stat MRI which showed menscius tear, ACL tear, and effusion around the joint. His labs showed an elevated WBC of 12, but his knee was swelling so I thought that was probably inflammation. So the office decided to refer my husband to an orthopedic doctor who initially wasn't going to see him for 3 months due to blood thinner treatment.

Well about 1 1/2 weeks later my husband is barely able to get off the couch. They have prescribed Percocet and Tramadol...we were mostly sticking to tramadol. But neither are really helping, he is having other joints swell and cause pain, his appetite is poor, he is sleeping most the day, and we have been weighing ourselves weekly and one morning I noticed he had lost 15 lbs. 15lbs in 3 weeks! That's how bad his appetite is. I call the MD's office and tell them all this because now I'm starting to be really freaked out as I am not sure what is going on anymore. All the NP tells the office staff to do is see if we can get the ortho appointment moved up and run another CBC, BMP. Labs are about the same and we have to weight 2 weeks to see the ortho doctor. I am frustrated at that time because I really don't think this is something for the ortho doctor, I think whatever is going on is more systemic, but I don't want to piss my husband's NP/MD off by being a 'know it all nurse wife'. So we wait. He worsens and we see the ortho doctor. Low and behold the ortho doctor agrees that he thinks the issue is systemic as well and refers my husband to a rheumatologist.

But we are on week 6 of my husband, a bricklayer, who hasn't been able to get off the couch. Like he is only taking a shower every 3 days because he does not have the endurance to do it more frequently. I think my husband has rheumatoid arthritis. Honestly though I'm not really sure what is going on, but I'm not really willing to let my husband go another month like this. I called the MD office to see if he could be on steroids until we get contacted by the rheumatologist because that was the last time my husband was sorta okay. The ortho doctor thought it was a good idea but wouldn't prescribe them as he will no longer see my husband.

But my husband's MD office says that the NP wants him to come back to the office and be seen before they are willing to prescribe anything or refer him to another MD. I ask if my husband can see the MD and not the NP and they are like, "well his care provider is the NP". I kinda feel like the NP knows as much as or less than I do. I never asked her about her experience because I thought it would be rude, but she comes off as someone who has not had much nursing experience before becoming an NP.

I feel like all the questions I ask her she doesn't know the answers to. Frankly I think that is because we are both nurses and those 2 extra years of school for the NP don't really amount to much more than a paper. Kind of just like my BSN...without the decade of experience behind it my BSN is little more than a trophy for suffering through school. I didn't learn how to be a nurse until well after I graduated. I think her experience doesn't lend to having anymore knowledge than I do and that is why I need to see the doctor. Whatever is going on with my husband is out of our league and I want to see someone better educated to know what our next steps are.

Am I way off base? Am I being ******?

[BostonFNP, APRN]

There are some things here which aren't what I would call "good medicine" but they seem to include both your MD and NP (aside from the NSAID comment which I hope was just a misinterpretation). I wouldn't be happy with the delay in diagnosis; there is a lot more than can/should be done prior to your husband waiting weeks/months to see rheum.

You need to be confident and comfortable with the providers taking care of you and perhaps this is a time to consider changing if your trust has been eroded.

There are also, being completely honest, some comments in your OP that are concerning and perhaps warrant a bit of self-reflective practice.

Hope your husband gets the workup he deserves and feels better.

[djmatte, ADN, MSN, RN, NP]

There's a lot going on here and probably outside the scope of what people *should* comment on in this forum. Anytime you lose confidence for any reason in your provider, it is probably better to seek alternate help. Try not to blow it out of proportion though as it's easier to just move on than to make a stink. I would be concerned about a reaction like this so soon after starting a new medication (xarelto in this case). So something to consider.

[caliotter3]

I have lost confidence in a provider for less than what you describe. It just might be better for all concerned to find another provider at this point.

[KalipsoRed21, BSN, RN]

Well I think that is really my question. I feel what is going on with my husband is more than his NP can handle. Mostly because I've been a nurse 10 years and she doesn't seem to have any more to add than I do when we see her. I didn't know if I was being a total jerk to demand he sees the doctor. Or if something about FNP school should make her capable of handling this? I thought that treating/diagnosing is what nurses went on to FNP school for. I thought that I should be able to expect from the NP almost the same level of knowledge that I get from the doctor. Most of the NPs I've worked with do seem to have a greater knowledge base than I do. But maybe what I thought about what NP school does for nurses is wrong and my expectations are off? Maybe most of the NPs I've worked with were very experienced nurses before they went to NP school and that is why their knowledge base is so vast? I don't want to diagnose people...that is why I never went back to school. I like being an assistant.

Boston FNP, I would switch providers if my husband was agreeable. But at this point I feel he is in serious crisis and what I need is for someone who knows way more than I do about medicine to come up with a plan. I have seen patients go both ways, weeks without care because they were provider hopping to much or weeks without care because they didn't leave soon enough. I think my husband needs to go to both a rheumatologist and a Heme/Onc doctor. But my insurance only covers if the MD refers. That has been another issue. His MDs office say they are calling and checking our coverage but the place they sent us to for the MRI was a black out site for my insurance, so we have to pay the whole cost. The first ortho guy they referred us to was not in network for my insurance. I had to go find my own and ask them to refer him. I asked about about heme/onc but the NP doesn't seem to think it is pertinent, but says she will ask the doctor.

[algae1492]

I feel what is going on with my husband is more than his Np can handle.

Speaking as a RN, it seems to be the reason why the provider(s) referred the patient to a specialist. It was out of their reach.

[BostonFNP, APRN]

Well I think that is really my question. I feel what is going on with my husband is more than his Np can handle.

If this was more than the NP is capable of (or allowed to) handle than a referral to a specialist would be appropriate. It sounds like this was done. As said before (and without getting into giving medical advice), it is well within the scope of training for either the NP or the MD to do "more" of a diagnostic workup.

Mostly because I've been a nurse 10 years and she doesn't seem to have any more to add than I do when we see her.

You should really reflect on your thought process here. You have been a nurse for 10 years and have no doubt developed some expertise in that role. As far as we are aware you don't have any experience or expertise in the PCP or provider role and these are two very different things. It comes off as putting an inappropriate emphasis on your experience while discounting a colleague's. I've never met either of you so maybe you are absolutely right, but it's something you can and should perhaps reflect on.

I didn't know if I was being a total jerk to demand he sees the doctor. Or if something about FNP school should make her capable of handling this?

You are not a "jerk' for demanding to see whomever you want. What does your husband want? He's the patient. If he wants to demand to see the MD that's perfectly fine. Honestly it sounds like the MD isn't helping either but if you have more confidence there you absolutely should request that.

Theoretically FNP school makes her more then capable of handling this. IF the individual provider feels she isn't comfortable with it than the appropriate action is to collaborate with a more experienced provider and refer to a specialist. It does sound like both of those things happened.

[DowntheRiver]

I believe you are very frustrated with what is going on with your husband and the fact that as much as you are trying to help him you are only able to do so much. I know that when I am frustrated, particularly with a provider, I start picking apart every little thing they say and do when on any other day it would most likely be insignificant. I kinda feel like that is what you are doing here. So, moving forward, if this were my patient, I would suggest that you need to continue getting care from this office for the time being. HOWEVER, I would seek out another PCP and set up an appointment ASAP. Where I live, it can take 2-3 months to get a new patient appointment unfortunately. I'd also suggest (if this were my patient) to just go to the ER. More than likely the docs there will see how severe this is and admit for a full workup. Not the best use of resources but sometimes that is just how you have to get things done.

[KalipsoRed21, BSN, RN]

Thanks for all the helpful comments. I will reflect further, I have limited experience with the PCP role. I am probably just frustrated at my lack of control of this situation. It is odd that I have more educational and process of care conversations with providers in providing care to strangers than I do caring for my own husband.

[missdeevah, NP]

If you feel that he is deteriorating rapidly, and can't get the care he needs fast enough, I would go to the ER. They will figure it out quick, but the costs associated with this are another story. If you've lost faith in your current providers, I would find a new PCP. It's important to trust the person that you entrust your health to. I wish you and your husband a quick resolution to this unfortunate situation.

[algae1492]

Thanks for all the helpful comments. I will reflect further, I have limited experience with the PCP role. I am probably just frustrated at my lack of control of this situation. It is odd that I have more educational and process of care conversations with providers in providing care to strangers than I do caring for my own husband.

Definitely never stop advocating, and push for more streamlined care.

[alwayslookingnp]

There is a lot going on here. First, your husband has a DVT and a torn meniscus. He also has arthritis. These are separate issues with different treatments. Your husband is also a bricklayer so may have some occupational issues (look up carpenter's knee). There is no quick fix for these problems, and it seems as if that is what you are looking for. I can see where these issues might involve family medicine, rheum, and ortho. Is compression ok for one condition or all 3? I am not surprised that the NP did not have an immediate solution for you. You don't like the wait time for ortho and your insurance had some problems with the one you selected. While I can understand your frustration with this, the NP is the starting point for this complicated place and not the endpoint of treatment. Yet, the NP is the one your frustration seems to be aimed at. If you have no confidence, then I think you should change but I do not anticipate the next provider will be able to provide short term solutions for what seems to be a long term problem.