Don't trust my FNP

[KalipsoRed21]

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 ******?

[TriciaJ, RN]

I personally do not think you are being a *****. You're worried about your husband and your guts are not feeling right about this situation. You would probably feel a lot better about his current providers if one of them could sit down with you and explain their thinking and the algorithm they are following. But they seem to be winging it while your husband continues to suffer with no diagnosis and no treatment plan.

Stop second-guessing yourself and worrying about how you come across. You need to advocate for your husband. If you later feel you stepped out of line, you can apologize with a food gift basket. Right now you need to keep your husband alive and alleviate his suffering. Do what you have to do and good luck.

Please keep us posted. I'll be keeping both of you in my thoughts.

[bitter_betsy, BSN]

I don't know how your insurance works - but with mine I can pick any provider at any time. Sometimes specialists require a referral (not because my insurance requires it but because they do). You are always entitled to a second opinion and have the ability to go elsewhere. If you are not confident in the care being provided - I'd go elsewhere. I'd go elsewhere based on the simple fact they weren't sending me to other providers that were covered under my insurance.

I hope you come to a resolution. I know what its like to have a fella at home unable to work - when they have spent the last 20ish years doing nothing but hard labor every day. It makes them even more miserable. There is very much a mental aspect to their inability to work that we have to address as well.

[NurseBlaq]

6 weeks of no relief and declining health? I would do what others have suggested and maybe go to the ER and avoid the long wait to see specialists. Not sure how your insurance works cause I know ER visits can be costly, unless admitted, and with all that going on he may just be admitted. Won't hurt to try.

[alwayslookingnp]

What bothers me about this line of thinking (bypassing specialists or any other recommended discipline) is that the ER does not take the place of a specialist. It will not take care of a chronic problem. A complaint like this one will likely be triaged to the fast track area. There, your husband will be seen by a NP or PA. This person may do some imaging and write a prescription but they will refer you to a specialist for follow up. In the end, you have bypassed nothing and have added an extra step and added expense to your care.I would recommend following up with the specialist you have been referred to.

[mushyrn, BSN, RN]

I see why this is frustrating, but as an RN (6 years) and ACNP student, the NP education is definitely more in depth and beneficial than the RN education.

Also, RNs are nobody's "assistant". Please get that thought out of your head.

Are you just trying to start something here? Haha.

[inthecosmos, BSN, MSN, RN, APRN]

With everything going on, I would heavily recommend considering a different PCP or requesting to see the MD your next visit.

[traumaRUs, MSN, APRN]

I'm an experienced APRN and would definitely recommend second opinion. ED is not the place to go - this is not an emergency and they don't have specialists in the ED anyway. As someone else said, this is now, unfortunately a chronic issue. It is going to take time and testing to figure this out.

Please ask for second opinion.

[jodispamodi]

Find another doctor... Has he had any exposure to ticks? may be worth testing for tick borne diseases

[Medic/Nurse, BSN, RN]

I think it can be a very emotionally complex matter when you are seeing someone you love suffer, yet, medically you find yourself in some strange quagmire of your efforts at advocacy being less than effective or outright ignored - you would surely start to become frustrated (I would prolly be near the 'Release the Kraken' - bad idea, FTR - stage by now as you have described the situation).

I would prolly be feeling peak frustration "I am a nurse. I always work hard to see that my patients get the best. Yet, somehow my husband is sick and seems to be falling through the proverbial crack, and I seem to be unable to do anything to stop this! Who the hell am I?"

The problem with this thinking is that it lets you misdirect focus on a systems issue, toward a provider. Yep, the NP may be inexperienced and may not know every nuance of every presentation (hint: no provider does ever) but, that focus doesn't get you any closer to resolution.

Just stay and play where you are for now. Cooperate and assimilate with the NP (and the group) for the good of getting expedient speciality care for your hubby. Even keep the Kraken locked up!

Just make a first available, ask for a from the top clinical review and assessment and plan of care going forward. Your hubby is miserable and needs a diagnosis. Period.

Enough of the blah, blah, blah from them. Answers. Treat or get into somewhere that can. On your insurance.

Never change docs during a crisis. Really.

The SUFFERING is real.

I hope you find peace. Keep us posted.

I'm pulling for you.

:angel:

[TuxnadoDO]

The primary, whether physician or NP, should be able to start an autoimmune workup with ANA, RF, Anti-dsDNA, etc. If all negative, no need for rheumatology. RA typically doesn't present with monoarticular arthritis in large, weight-bearing joint. Now that he's having other joints inflamed, I would say it's reasonable to run the initial autoimmune panel, even more so if he has a family history of autoimmune problems. Did the Ortho doc perform an arthrocentesis? That itself would diagnose inflammatory vs noninflammatory arthritis, and also rule out crystal arthropathy or infectious cause.

Secondly, did your husband have any reason for the DVT or is cause unknown? If unknown, he should have a hypercoag workup. This, too, should be done by his primary.

If one of my patients requested a second opinion from my colleague, as long as it was communicated politely and respectfully, I would have no problem with that. I would suggest trying to communicate with his provider(s), explain your frustration as calmly as you can, and ask for a differential diagnosis, and what the next steps are.

I am an ER physician and this is my first post here. I have read a bit on the site, purely to help me understand my nursing colleagues better. I'm less than a year out from residency and supervising PAs and NPs, and have found this site to be very helpful. So, I hope no one minds.

edit: If you've already seen an orthopedic surgeon, the ER is not likely to have anything to add. If this has been going on for weeks, there may be something serious although it is not likely to be an emergency. If he spikes a fever or has abnormal vital signs, then yes I agree with going to the ER.

[NurseBlaq]

The primary, whether physician or NP, should be able to start an autoimmune workup with ANA, RF, Anti-dsDNA, etc. If all negative, no need for rheumatology. RA typically doesn't present with monoarticular arthritis in large, weight-bearing joint. Now that he's having other joints inflamed, I would say it's reasonable to run the initial autoimmune panel, even more so if he has a family history of autoimmune problems. Did the Ortho doc perform an arthrocentesis? That itself would diagnose inflammatory vs noninflammatory arthritis, and also rule out crystal arthropathy or infectious cause.

Secondly, did your husband have any reason for the DVT or is cause unknown? If unknown, he should have a hypercoag workup. This, too, should be done by his primary.

I am an ER physician and this is my first post here. I have read a bit on the site, purely to help me understand my nursing colleagues better. I'm less than a year out from residency and supervising PAs and NPs, and have found this site to be very helpful. So, I hope no one minds.

Welcome to AN. Maybe you can also provide us nurses some feedback and a different perspective from an MD point of view. Post away!

[GoodNP]

The primary, whether physician or NP, should be able to start an autoimmune workup with ANA, RF, Anti-dsDNA, etc. If all negative, no need for rheumatology. RA typically doesn't present with monoarticular arthritis in large, weight-bearing joint. Now that he's having other joints inflamed, I would say it's reasonable to run the initial autoimmune panel, even more so if he has a family history of autoimmune problems. Did the Ortho doc perform an arthrocentesis? That itself would diagnose inflammatory vs noninflammatory arthritis, and also rule out crystal arthropathy or infectious cause.

Secondly, did your husband have any reason for the DVT or is cause unknown? If unknown, he should have a hypercoag workup. This, too, should be done by his primary.

If one of my patients requested a second opinion from my colleague, as long as it was communicated politely and respectfully, I would have no problem with that. I would suggest trying to communicate with his provider(s), explain your frustration as calmly as you can, and ask for a differential diagnosis, and what the next steps are.

I am an ER physician and this is my first post here. I have read a bit on the site, purely to help me understand my nursing colleagues better. I'm less than a year out from residency and supervising PAs and NPs, and have found this site to be very helpful. So, I hope no one minds.

edit: If you've already seen an orthopedic surgeon, the ER is not likely to have anything to add. If this has been going on for weeks, there may be something serious although it is not likely to be an emergency. If he spikes a fever or has abnormal vital signs, then yes I agree with going to the ER.

Been reading this thread and hoping somebody was going to say this (wish it had been an NP)

In your husband's case, one potential benefit to seeing hem/onc is maybe they can give some insight into how safe it would be to hold xarelto a bit so he can get a knee injection/aspiration? Something to bring up with the NP if she needs a little convincing.

Also, since you aren't able to schedule with the MD, I don't think it's unreasonable or impertinent to ask the NP to discuss the case with the MD. I have had a patient ask this, and I was not offended. We should not be too proud to accept that we don't know what we don't know, and let's face it the MD knows more than we do (or should). The most dangerous provider is the one who doesn't recognize her own limitations.