NUTR 710

Last week at High Point but the end is not quite here

2009-08-09T19:13:00.000-07:00

I finished my last at High Point last week. I was able to focus on oncology and rehab patients all week, which was definitely a treat given they were the patients I most enjoyed working with. It was a bit of a slower week, so I was encouraged and able to spend more time with each patient. Mostly, that meant spending time listening to them tell me about their lives and histories whether it had to do with their eating habits or not. It was great, and I loved every minute of it! One patient spent spent over 45minutes telling me stories from his WWII days in Europe. Not only was it fascinating, but low and behold I learned about where some of his eating habits came from! I am more convinced than ever that the power of listening has the ability to heal...or at least make people feel a whole lot better.

I start a one week rotation this week at UNC tomorrow focusing on inborn metabolic disorders. I feel like it will be a complete change of pace in many ways yet should also be very interesting. I am looking forward to it!

goodbye CMC Union

2009-08-07T15:07:00.000-07:00

I left to go out of town the day after my clinicals finished, so I didn't get to write my last post until now. My last two weeks at CMC Union were a very good experience for me. I was on staff relief both weeks, and it was the first time that I really began get to know the patients on the floor. Before I just usually went with whichever dietitian had the longest list, so I rarely followed up on the same patient that I had already seen. Staff relief was a great way to see the parts of clinical dietetics that I enjoyed and the parts that were not my favorite.

I was sad to leave the dietitians on my last day because they were very good to me all summer. One of my favorite parts of the summer was interacting with them every day. Overall it was a great summer!

Ending on a High Note

2009-08-01T13:19:00.000-07:00

My last week of staff relief definitely had its ups and downs, and I was pretty much exhausted for most of it, but it was a great week in the end. I followed several patients over the course of the week, and it was great to get to know them and help them. I did a lot of instructions, and most of my patients were remarkably receptive, making the experiences really positive. (However, I did learn that you should NEVER calculate someone's energy needs on the fly because it is way too easy to make a mistake, and then you have to go back looking like an idiot.)

I heard some interesting food beliefs from several people: 1) when you add salt during cooking instead of at the table, it doesn't add sodium to the food, and 2) sea salt has less sodium and is better for you than table salt.

The exception to my feeling of being able to help everyone was my very last case: a woman with a h/o severe hyperemesis gravidarum. As I dug into records from previous admissions, it became clear that there isn't much we can do for her - jejunal feedings and TPN have both failed in the past, and she ultimately had to terminate a pregnancy. I spoke with her briefly to let her know that the RD's would follow her and give her all the help possible, but really, this woman just has some tough choices in front of her.

Overall, this has been a really challenging but educational and rewarding. I will really miss the RD's at Rex - they were so helpful and fun to work with. They've all been very supportive, including Lyn (the demanding clinical nutrition manager), who went out of her way to compliment me on Thursday. I'll take that as an H.

pickled pigs feet!

2009-07-31T13:28:00.001-07:00

Today was my last day at CMC and it was definitely bittersweet! I was almost trapped there due to an overturned tractor trailor that spilled pickled pigs feet all over the lone road that leads to the hospital. Luckily they were able to clear most of the mess in time for my departure.

It's really a relief to be finished, but I'm definitely going to miss the dietitians that I worked so closely with. They were all really great teachers - always supportive, encouraging and patient with me, and willing to answer any questions I had, despite being very busy. This whole experience has been a very positive one and Cayuga was a perfect environment for me to learn and develop professionally. Today the dietitians and nutrition assistants even threw me a good-bye party complete with an AMAZING flourless chocolate cake and presents. It was really hard to leave!

goodbye!

2009-07-30T18:26:00.000-07:00

i just have to say that i'm actually a bit overwhelmed that tomorrow is our last day at unc. i've been on staff relief as well, like sarah mentioned...covering peds this week because a peds dietitian is away getting married. it's been a great but definitely busy week. i honestly don't even know what to write right now. (haha) i think i'm just realizing that this is all the training we're going to get (if we choose to go the clinical route).
anyways, i think the highlight of this week was my cute baby girl with curly curly hair, who is always alone in her room. i'm drawing a blank but i think she was born with a defect where her esophagus and stomach are not connected. so, this sounds crazy, but they are "stretching" her esophagus and literally just waiting until it's closer to the stomach so they can surgically connect them. so anyways, I stepped in to check on her tube feeding and she was awake, crawling around her crib so i stuck my finger in to just say hi. she grabbed my finger and wouldn't let go...so we ended up playing together for awhile. totally not nutrition related i guess, but it was just a nice feeling to see that the nutrition she was getting was giving her the energy to be happy and moving around again.
anyways, hope everyone has a great rest of summer! woo!

4 hours left!

2009-07-30T16:24:00.000-07:00

I'm working a half day for my last day, thus the 4 hours left. I am ready for Nashville, TN.

I spent the first 3 days of this week at UNC with a wonderful RD named Jennifer who works as a ketogenic diet dietitian on M/T and helps with other specialty areas on W. And I got to spend a bit of time with Sarah and Diane and hear Caroline's case study. On M/T we basically focused on one patient who was a 1yo little girl with severe seizures. Her mom desperately wanted to try the ketogenic diet and fully believed in its healing potential. She was on top of things. She read a whole book about the diet, constantly stayed at her daughter's side taking care of every need, bought the highest priced scale available to measure out formula and make different ketogenic recipes, and was willing to try anything Jennifer recommended regardless of the cost. I should mention that this mother was obviously not of a high SES and wore tattered clothing each day we were there. What a beautiful example of unselfishness she provided as she gave up everything to take tremendous, compassionate care of her little, suffering baby.

On W, we also saw a 17yo boy with CF who was on TF at night to help meet his needs. I never realized how annoying TF can be until he started talking about it. He said it makes him sick to even think about the formula being pumped inside of him, so he has to do it at night. But he rolls over a lot and pulls out the tube from the site, so his bed gets all soaked with formula. And his site leaks a lot, and he says that the acid leaking from his stomach burns his skin. Awful. I should have just recommended Cook Out milkshake TID (which would only have met 1/2 his calorie needs unfortunately).

I am about to burst with excitement about being finished. I will definitely be sad to leave all of my new Fayetteville friends though. A tear may be shed...

ICU

2009-07-30T15:10:00.000-07:00

It seems like I will be tackling a pretty interesting case tomorrow on my last day. An ICU patient came in today with a complication of a gastrostomy. He had an exploratory surgery of his stomach that somehow went terribly wrong. He has a hx of throat cancer so he already had a PEG tube placed. Somehow the patient perforated his stomach and tore his esophagus while vomiting, so his PEG isn't usable. Now instead of the normal port on his PEG, they somehow attached a tube and it runs out of his stomach, to the outside of his body and then back into his jejunum. I guess that plan was to feed him through that, but since he perforated his stomach, they aren't feeding his gut at all, obviously. He was started on TPN today, but he has a pretty poor prognosis. His stomach contents leaked out into his abdominal cavity and possibly into his lungs. Looking back today I can't even imagine how I would have felt seeing this kind of case when clinicals started, and it makes me realized how far I've come. I'm hoping we can make some appropriate recommendations for the patient tomorrow.

Almost the end.

2009-07-30T11:08:00.000-07:00

What a day. Today I have had quite a few challenging heme/onc cases. My most difficult case was a young man with AML who currently has GVHD of the gut/skin/liver, a pneumothorax, decreased urine output, potential liver failure, and BK virus in his brain. The patient's MD indicated he has never seen a patient with BK virus in the brain. I know the medical team is similarly overwhelmed with how to manage the patient. Anyhow, he is on TPN, which was actually discontinued yesterday due to fluid overload. His triglycerides and lipase are elevated. The current debate is whether or not to remove lipids from his TPN. The TPN pharmacist said lipase is not needed to digest IV lipids, but if his TG are super elevated that may be a reason to discontinue lipid administration. The patient is intubated and sedated and has a number of other medical complications that are too complex to explain at this time. Anyhow, from a nutrition perspective, we are currently waiting for the TPN orders to be reinitiated and then we will restart his parenteral nutrition. His labs will be measured again before writing the order. Today his potassium was elevated, and he had diarrhea. Complex. Diffcult to treat, but much more difficult to observe. The most challenging aspect has been juggling what to focus on with abnormal labs, diarrhea, liver failure, fluid overload, etc. All nutrition efforts seem contraindicated....

Well, tomorrow is officially my last day. Still cannot believe this summer has passed so quickly. I have learned a ton and feel much more prepared to enter the field. Exciting.

Rachael

Radiation/Oncology

2009-07-30T08:07:00.000-07:00

Today is my second to last day at CMC. I have been covering an entire unit this week. Luckily it hasn't been super-busy! My unit is a general medical floor where most of the patients are geriatric. Many are hospice, comfort care or waiting to be placed in a nursing home. For the most part I am ordering supplements or just "following-up as needed" since many are NPO due to unresponsiveness.

Yesterday, I spent the morning with the Radiation/Oncology unit. I shadowed a few outpatients with cancer through the process. My first pt was a lady newly diagnosed with pancreatic cancer. She was first assessed for a process called 'gating' where they tape a small rectangular block onto the abdomen while she lays down on a CT scan table. The purpose of this block is to measure the wave of her breathing. Once they get a steady pattern of breathing measured, she was moved to another room with a similar set-up. This time they performed an actual CT scan. The gating process is used in patients where they think that the tumor experiences a lot of movement due to breathing. Gating allows the radiation to be applied in a more specific manner, targeting the tumor as it comes away from the body, to try and limit the amount of radiation that is applied close to the chest cavity. Once this was complete, the patient was free to go - but not before she was permanently tattooed with four black dots on her abdomen so that her radiation could be applied more precisely each time she comes in for treatment. I never realized how demanding a radiation regimen was. Pt's come in 5 days per week for about 2 months.

Last day

2009-07-30T07:13:00.000-07:00

Today is my last day and yesterday was the last day working with patients. This summer has been a great learning experience. I now know way more about TPN and diabetes than I ever expected. Overall I realize in a hospital always expect the unexpected. I hope everyone had a great summer. See everyone in a few weeks!

LAST DAY

2009-07-29T20:51:00.000-07:00

I had my last full day today. Fortunately the outpatient clinic was busier and we actually had 3 patients this morning. The first patient was not receptive at all, but the second two were a joy to work with. One was an elderly gentleman who wanted to lose weight and supposedly had HTN and dyslipidemia, though medications seemed to be controlling both conditions fairly well. The second gentleman was very young and he came in with his wife. He had surprisingly high blood pressure for his age. They came one right after the other and the most striking thing was how differently they carried their weight. The younger gentleman had a BMI of about 35 and the older gentleman had a BMI of about 36. However, the older gentleman appeared obese and carried a significant amount of the weight in his abdomen, whereas the younger gentleman looked overweight, but not obese at all. This was a good reminder that BMI can be deceptive.

I forgot to mention that last week one of the dietitians called to tell me that one of the patients I had reassessed had been taken off her tube feeding. Apparently she had refused to eat a while back, and so was put on tube feeding. The patient has severe dementia, so when I did my evaluation I spoke with a nurse to get information about her. In the conversation the nurse mentioned that this woman would eat little bits of food that were occasionally offered to her, and so I asked the dietitian to put in a consult to have the patient evaluated by the SLP. Apparently the results indicated that she was safe to eat and she no longer is being tube fed. I was very pleased to hear the news.

H.O.N.K. if you love Jesus

2009-07-29T19:56:00.000-07:00

I went in to a room today to educate a patient about a diabetic diet. This 45 yo man's admitting diagnosis was H.O.N.K. There was one mention of dementia in the chart, but no documentation of any altered mental status, so I didn't expect what I got when I asked the patient if he followed any type of diet at home before coming in to the hospital. He told me: "Jesus don't want me to drink diet soda and fake sugar because the body is God's temple."
Amazingly, I even surprised myself with my ability to keep a straight face and respond in a serious voice with: "You're right, your body is a temple and you need to make sure you do the best job of controlling your blood sugars so you don't damage that gift from God." Clearly the man was nuts, but I attempted to reason with his dementia... (maybe that's a sign of my semi-dementia from doing this for 12 weeks already)... Then we proceeded to talk about carbohydrate counting and I steered clear of the topic of artificial sweeteners for the next 10 minutes. My initial comment seemed to work, though. Either that or it just confused the man long enough so that he at least listened to what I was saying. However, I am not easily fooled... I expect this patient to return in a week, just like the rest of them.

dia-bet-es

2009-07-29T19:03:00.000-07:00

I cannot believe we are almost done with out internship. Crazy. Anyhow, this week I have been on staff relief. I chose heme/onc and pediatrics. Spending my time shared between adults and pediatrics has been interesting... percentiles vs %IBW vs growth charts vs parents... etc. Anyhow, today I completed my first "pediatric" diabetic diet education... and boy was it different from adult diet educations. I spent nearly 2 hours talking with the patient and her parents. The patient was only 9, so trying to explain any sort of exchange system/carb counting seemed nearly useless. She was completely lost throughout the session and developed a headache midway through. The parents expressed a similar confusion as the patient. I kept asking for food preferences/usual meals and the same answers -- pizza, fries, bagels... oh, she doesn'treally eat fruit or bread or vegetables -- continued to surface. About 10 times I explained that 1 carb choice = 15 grams of carbohydrates, and meats and cheeses do not count as carbohydrates. The mom started crying and... well, needless to say, it was a little hectic. I actually enjoyed it though. I enjoyed the concern the parents had for their child and their interest in the information presented. I enjoyed the time I spent with the family, and the opportunity to provide support during this difficult time. It was all a new experience, and I learned a lot in the process. Looking forward to my last few days at WFUBMC. Wow, this summer has passed quickly!

Rachael

Georgetown Week 12!

2009-07-29T17:37:00.000-07:00

Clinicals are coming to an end, and I am more than ready for a break!

I'm doing staff relief as well this week, covering the medicine floor and some of the MICU (which I requested).

I had an interesting pt yesterday - he was intubated, on propofol, HD, and had an elevated Phos, with K on the lower end. I had to think for a minute before choosing the most appropriate TF formula and rate. My first thought was to choose Promote because it's low in fat, but then I noted the high Phos and wanted to go with Nepro at a lower rate to account for the propofol. But then I noted the pt was on HD, so his energy and protein needs were especially elevated, but protein needs could not be met with a low rate of Nepro. Also, with the Nepro at even a low rate goal + propofol, the pt would end up with 67% kcals from fat! But the phos in Nepro was significantly lower than Promote, and Nepro is much more concentrated so less fluid is ideal for HD. I was a bit worried about the K going lower with a low electrolyte formula, but we could just trend it. Although I did think about still going with the promote and adding a phos binder. In the end I chose Nepro. With propofol I recommended a lower rate + beneprotein, and when propofol is d/c'ed I recommended to increase the rate with no Beneprotein. I learned that high phos trumps too many kcals from fat, especially since it'll will only be temporary, as propofol isn't used LT. And it's best to avoid phos-binders if we can manage the phos through the TF.

See everyone soon!

Finished!

2009-07-29T16:53:00.000-07:00

I said all my goodbyes today.

Turns out, my very last day on the job turned out to be one of my hardest. I had a patient irrationally demand I leave his room (poor guy, I told him what his cholesterol level was and he about cursed out the whole medical community), I left my pocket brain behind on one of the floors, and it took me FOREVER to start on my case load because I couldn't get my hands on the right charts at the right times (I ended up leaving the office at 7pm)....Luckily, the R.D.'s catered lunch in honor of my leaving today! One of them even made a homemade carrot cake for me that said: "Best Wishes Amaris" in green frosting. I don't think I've had a frosted cake like that since my 10th birthday! It was awesome. Anyway, just had to share.

See you all SOON!

Enjoy vacay!

2009-07-29T16:46:00.001-07:00

This week at UNCH featured a cameo from Laurie Bennie and it was nice to have another friendly face in the nutrition office.

I’m on staff relief this week, and despite having had dreams about consults in distant parts of the hospital accessible only by monorail, the census dropped and it actually has not been overwhelming. I did almost embarrass myself today when I began to follow up on a TF that never got started. Good thing I checked the nurses’ notes before heading up to the patient’s room because apparently he died early this morning.

I saw a delightful patient who didn’t know that he has had chronic kidney disease since 2005. He had been trying to “be healthy and lose weight” by eating more fruits—like bananas and oranges—and had been taking vitamins—like potassium supplements for his leg cramps. He was admitted 2 days ago with hyperkalemia (K was 6.6) and now is starting HD. He was really disappointed to learn that many of his favorite fruits and vegetables were high in potassium but was quite agreeable to switching to low potassium options and eating sorbet rather than ice cream as a dessert.

Thanks for the interesting blog posts this summer – it was fun to hear reports from everyone else’s experience!

The End is Near

2009-07-28T20:08:00.000-07:00

I have been with the outpatient dietitian for the past two days, and while it has been painfully slow, there have been some noteworthy moments. Also, it has been an eye opening experience to see the contrast of inpatient verses outpatient. The clinic has some scheduled appointments, but they also take walk-ins. Many of the patients cancel their appointments or just do not show. So it is a bit frustrating.

Only 2 patients have come in when I have been there, and in both cases they were very kind and appreciative of the information. It is nice having the patients coming to you for advice when they are healthy and do not have other things on their mind, rather than trying to educate them when they do not feel well and are distracted by their surroundings. Other benefits of outpatient counseling include having more time with the patient and having more resources, such as their medical record with lab values and food models.

I also was able to observe a weight loss class that is part of the MOVES program at the VA. Unfortunately only one participant attended, but the diet tech taught the class anyway. The patient was very open and enjoyed telling stories. Some of them helped explain his struggles with food and weight, which he claimed was near 400 lbs. Not only were his stories interesting, but it was valuable for me to hear what his life is like. I think the experience will help me to better understand and empathize with patients in the future.

Making more work for myself

2009-07-28T17:39:00.001-07:00

It's my staff relief week at Rex, and I choose to work on 5W, the unit with the most interesting hodge-podge of cases (cancer, FTT, fungicemia, drug OD's, etc.). Since that's not enough to keep one person busy, I was also assigned the other hodge-podge floor, which has apparently become the DM wing. Every morning, I get several consult orders to clarify the MNT order for DM patients (i.e. determine how many gms of CHO they should get at each meal). Several have turned out to have ESRD and other significant health problems. So 2-3 times, I've gone on to do a full assessment: getting a full PMH, speaking with the patient, carefully determining protein, potassium, sodium and CHO needs, making extensive recommendations in my notes, etc. Today, the RD who's signing my notes told me that she changed them to just a clarification of the CHO needs. If the MD doesn't order a renal MNT, she said, she usually won't order it since she assumes there's a reason for it - and usually they aren't eating well enough to exceed a limit anyway, so it could hurt them more than help them to restrict something. I've come a long way in 12 weeks, but it also means it's been a long time since my renal rotation! I guess this is why I had never done an assessment for a renal pt based on this kind of consult before this week...

Farewell to Moore Regional!

2009-07-28T13:06:00.000-07:00

Tomorrow is my last day at MRH, and I must say, I can't believe the day is already here (but I guess I'm just echoing everyone else who's posted). Today I was on staff relief for the R.D.'s, and it was a lot of fun! I'm blown away at how much I've learned when I compare week 1 to week 12!
Today each of the R.D.'s gave me one or two pts, so in the end I actually ended up with more pts than any of the R.D.'s. It's worth noting here though that while I had the greatest case load volume-wise, it wasn't the greatest case load intensity-wise :). Not that I still don't have much to learn, but every day of this internship has given me the opportunity to put into practice the answers to yesterday's questions.

Anyway, the R.D.'s are taking me out to lunch tomorrow, which was an unexpected surprise! I'm looking forward to keeping in touch with some of the contacts I've made this summer.

Best wishes to everyone in their last week!

Georgetown Week 11

2009-07-27T16:58:00.000-07:00

On Monday, I spent the morning with a nurse in the hemodialysis room. She showed me the whole routine - how to prep the machine, how to hook it up to the pt (Mediport), and how the machine works. In this case, the red/arterial line was difficult to draw blood from, so she had to reverse the lines. She showed me the catheter tip with the holes for each line, and explained that the holes are strategically placed so that when the clean blood comes back in, it flows with the blood in the artery, and it gets quickly flushed into circulation. In reversing the lines, there is a chance that you could just be recycling the same blood over and over.

The rest of the week I was with inpt and outpt small bowel transplant, peds and adult. Apparently, people come from all over the world to see the docs here for small bowel transplant. It was very interesting!

I saw one kid in clinic, he was so cute! about 13 years old, but very small. He's been waiting for a transplant for over a year, and came in for a check up. He has Hirschsprung's disease, and his abdomen was huge, I could not believe it when I saw it. I knew his abdomen would be distended, but I was NOT prepared for this, I honestly thought there was some padding under his shirt, but then they lifted his shirt and it was just him! But the rest of him is tiny because he doesn't absorb most of his food because the intestine is so dialated. At first he was in a good mood, joking around and asking if he would be able to watch a videotape of his surgery. Then, the doctor asked for updated labs, and he started to tear up because he hates getting his blood drawn, so sad! His mom was saying they really hope to have the surgery soon because he is going to start high school in a year and he wants to play basketball and girls are starting to come into the picture! The good news is, his primary doctor said he's barely started puberty yet, so he will have time to catch up absorption and grow after a hopefully soon transplant!

I also sat in on a meeting with a pt who is thinking about SB transplant. It was the pt, her best friend, the surgeon, the dietitian, and me! It was so helpful hearing the surgeon explain why people get SB transplants, how it works, the recovery time, and lifelong meds, etc. In this case, he thinks the pt is a good candidate for transplant because she is TPN dependant, anything she eats goes straight through her because of multiple bowel resections which resulted in short gut. In this case her liver is fine so far, but she's had multiple line infections. The vessels on her whole right side of the upper chest are all clotted, so she now has a line on the left side. One thing I didn't even think about before - if a pt keeps getting infections, scar tissue begins to form, and the vessels start to clot, so a pt could eventually run out of access points for TPN and die from starvation/malnutrition. We also talked about how pts are matched with donors - blood type, CMV positive or negative, sensitivity (her blood is matched against 100 random samples and tested for rejection, then assigned a score), size (she was a tiny woman in her 50's who needs about an 8 yo SB). This was probably the most effective, informative, interesting experience of my clinical internship!

Georgetown End of Week 10

2009-07-27T16:50:00.000-07:00

I worked the weekend shift 2 Saturdays ago. It wasn't too bad, we only had about 7-8 pts total. I saw a couple on my own, and I finally got to see a pancreatitis pt! It wasn't chronic, and the pt was already started on clears x 2 days, which she was able to tolerate well. I recommended to advance diet as tolerated to low fat diet, and ASAP because the pt was asking for food and refusing to eat the clears diet because it's not "real" food. I found out from the RN her friends were sneaking her food!

23.6

2009-07-27T14:24:00.000-07:00

23.6 is the hemoglobin A1c level of a patient I saw today. A 29 year old. Who was conscious and alert and not in DKA. He presented with renal problems (shockingly, right?). I never dreamed a HgbA1c could be that high--and I mean, no he wasn't taking his meds or checking his BG levels, but... wow. And he wasn't very thin or anything-- I think his BMI was around 25 or 26. My mind is still blown.

In other news, staff relief is going well. The census has been down so we haven't been swamped, which works out well for me. We had a baby shower last Thursday for one of the RDs. I learned that there are regional differences when it comes to nursery rhymes: while I always heard "1,2, buckle my shoe, 3,4, shut the door" apparently some people say "1,2, buckle my shoe, 3,4, knock at the door." The meter is totally off on that one! And I lost the contest over that one, although I did win a lovely pair of earrings with the word scramble game, so that was nice. The food at the shower (we did a potluck) was, of course, delicious. When I shadowed the pregnant RD, people were forever commenting on her pregnancy and trying to touch her belly. To be fair, she was the most pregnant-looking woman I've ever seen (and she's still only at 35 wks), but I swear, you'd think people had never seen a pregnant woman before. I mean, there are tons of them walking around the hospital every day. I kept a tally of the number of comments she got a couple of days. That was fun.

Congratulations!!

2009-07-27T06:56:00.000-07:00

Hello Everyone,

Congratulations on making it to your last week of clinicals!!!!
Just a few reminders as you close out your paperwork:
-Your CNM or Student Coordinator needs to sign both your final joint appraisal AND your completed competencies
-Make sure you have obtained any "visuals" you may need to explain your special project
-Obtain any educational handouts, etc. that you might find useful your first year of practice (ask if you can have one copy for your files)
-Write a thank you note to your CNM for a great experience

Also, I HAVE CHANGED THE DUE DATE for your binders. Please bring your binder to my office on the 1st day of class (August 25, 2009).

Have a great week!

Amanda

Start eating to clean out the refrigerator....

2009-07-26T07:48:00.001-07:00

...because we only have five days left of the internship :)

I spent the past three weeks with the Metabolic Support team, practicing TPNs and working on tube feeds in the ICUs. The group consisted of five RDs and one PharmD, all carrying the extra CNSC certification. The past three weeks have been the most stimulating of the internship. I was originally supposed to spend two weeks with them but I was enjoying the challenge so much that I asked to replace my relief week with some more time with Metabolic Support. Starting tomorrow, I begin my Peds week--this team handles the children coming into Mission regardless of TPN, TF, or po status. I'm looking forward to hanging with the babies for a week, but I get the sense that I may have some difficulties with the neglect, abuse, and genetic defects which caused their admittance. I'm hoping to emphasize any positives, though.

I'm looking forward to sleeping in my own bed again.

Adult Outpatient

2009-07-25T09:06:00.000-07:00

I love outpatient! I spent the week with the RDs who cover the Ob/Gyn, Family Medicine, and Eating Disorders clinics, and each experience was incredible. I think the big difference is the change to talk with people who are basically healthy and who have come to see an RD. The range of issues - especially in the Family Medicine clinic - is definitely enough to keep an RD on her toes. I think the 2 most challenging parts of that job are keeping up with the wacky nutrition information on the internet and weight loss counseling. Does anyone know if there is ANY truth to the "avoid yeast product to avoid yeast infections" recommendation (eg, Candida diet)? We looked it up for one patient and found nothing but quackery.

The Eating Disorders experience freaked me out a little. One 15-year-old was super confrontational with the RD, and watching their session really illustrated how much of her food issues were about power and control. The eating disorders RD uses more motivational interviewing techniques than any of the other RDs I've spent time with, which was cool to see in action. I don't think I really have my mind wrapped around eating disorders, and would have to spend a lot more time reading and talking with people to understand them if I were to work in that area.

7 day countdown...

2009-07-24T14:32:00.000-07:00

I have to say, while I am very excited to see the end of the summer come (and finally see my family after much too long of a time), I will definitely miss the people at Cape Fear. They are kind of like my substitute family for the summer :) A somewhat dysfunctional one, but a family nonetheless. Well, this past week has been kind of slow (minus today... Fridays are always super busy). I helped with outpatient counseling several times, did the assessments for the minimal amount of children that we have here, and provided some staff relief when needed. Cape Fear had a carnival today to congratulate all of the hospital staff for performing well when Joint Commission was here, so that was fun. I hadn't eaten cotton candy in a good 15 years. I'm coming to UNC next week to shadow the RD that works in the ketogenic program, so should be interesting! And I get to watch a gastric bypass next Thursday back at Cape Fear, so that's fun too. Ok, have a great weekend ladies! See you soon!

Getting Attached

2009-07-23T21:38:00.000-07:00

I did a reassessment today on a patient I had seen near the beginning of the summer. I didn’t see him for over 3 weeks while I was in long-term care, and in those three weeks he had his leg amputated! He had a very bad ulcer on his foot when I left and I am not sure if it was related to his DM or just a very bad pressure sore. This news came as quite a surprise when I went to reassess him.

I have taken quite a liking to this older gentleman, and today I had some extra time, which allowed me to have several conversations with he and his wife and the nurses in charge of his care. He is a rather picky eater, and so I did my best to provide him with more appealing meals, and to ensure he receives the supplements he has been prescribed. I put into practice the information I learned from that ADA article we read about liberalizing diets for older adults. I was very thankful to have read that article, and to have research supporting my decision to make exceptions and allow him items that did not fit into the set meal pattern of his prescribed diet. The RD I was working with fully supported the decision as well.

Yesterday I was thrilled to see two patients from long-term care, who had been in pretty bad shape, out and about in motorized wheel chairs looking as happy as could be. It put a smile on my face that lasted the whole way home.

Having more fun with LTC

2009-07-23T20:38:00.001-07:00

The past few days at Rex's rehab/LTC facility have been much more interesting.

I've gotten a lot more patient contact, including rounds. (And I don't mean rounds like in the hospital, where care providers get together and run through a list of patients. I mean actually going to every room in two halls and talking with every patient about their concerns and needs.) A surprising number of people really liked the food, so we really just made small changes and answered questions. One woman, though, is the grandmother of a chef at the main hospital, and she said everything tastes awful. She couldn't be more specific about what she didn't like - it was everything. "Is it just different from what you're used to?" I ventured. "No, I like all sorts of different foods...as long as they're good." So now she's getting VIP treatment, including food off of the more gourmet hospital menu. Fortunately her roommate is verging on comatose, so we don't have to worry too much about other residents asking for similar perks.

On Wednesday, I got to observe the PT's working with several patients, many of whom I had already seen. It was great to see them in a different setting, being more active and pushing themselves. I realized why nutrition support is so important - we have to provide the energy and nutrients allow patients to walk again after a stroke or hip replacement. I particularly love a 95 yo woman who chugged away at her hand wheel exercises, and a sweet-tempered woman who suffered a hemorrhagic stroke that left her severely aphasic. (The latter has refused tube feeds and is making remarkable progress on eating.)

Today, I sat in on patient care meetings, where patients and families can talk to the social worker, nursing administrator, activities coordinator and RD all together. The family dynamics and interpersonal issues were particularly interesting. It was great to see the RD play a more collaborative role, working on overall quality of life rather than focusing on just nutrition. One case involved a 93 yo woman who is too exhausted to eat or go to the bathroom, much less engage in activities, because she refuses to take a nap. More specifically, she refuses to get into bed in the middle of the day because she thinks that means she'll die. We all worked together with her son to brainstorm strategies to meet her needs without forcing her to do something that scares her.

Oh, and I've also been told twice, both times by women who weigh less than 90 lbs, that I need to eat more and gain weight. What are you supposed to say to that?

so close

2009-07-23T17:44:00.000-07:00

Only 6 more days (thank goodness)! I am halfway through staff relief which is not my favorite thing in the world- and I'm just praying that the pregnant RD makes it through until her due date or next week is going to be absolutely miserable for all of us. Just as long as some of the patients get better soon and our census drops, next week should be much better. Besides just being generally annoyed with being busy- I realized two important things about this: 1) Trying to see too many patients in one day means that none of them get the best care. 2) If I ever manage a group of people, I will try very hard to never allow them to become understaffed.

ICU

2009-07-23T15:43:00.000-07:00

I started in the ICU this week, and I am generally surprised by how similar it is to the rest of the hospital in terms of what RDs do. There are more patients on tube feeding than the rest of the hospital, but other than that, it's basically the same. It seems like a lot of end of life issues come up at this hospital. Some of the patients have no hope of recovery, but there was no plan in place previously about what to do in such a situation. In one particularly terrible situation, a woman is basically brain dead with no chance of recovery and her family has yet to come see her. She is apparently a pretty frequent visitor to the hospital, and Adult Protective Services has been called each time she has been in. She usually leaves the hospital and is placed in a home, but her common law husband comes and takes her home just after she arrives at the nursing home. She is disabled and her "husband" doesn't take care of her. Apparently on her last admission, she had roach eggs growing in her hair because he hadn't bathed her in so long. On this admission, in hopes of avoiding protective services, after she initially became ill, he waited an hour or so and bathed her before calling 911! He went on a vacation just after she was brought to the ICU, because he "couldn't handle it", and nobody has heard from him since. Her son claims he has no car, and won't come in to visit her. The doctor is in a hard situation, because there is family, so she needs their permission to do anything, but they aren't present, so she can't discuss options with them. The care manager has worked to have a ride provided for the son, but he still doesn't come in, so all in all it's a pretty terrible situation. It just highlights the need for everyone to have their wishes about end of life care clearly laid out, just in case.

Is it already that time?

2009-07-23T15:41:00.000-07:00

I never thought I'd say this, but I think I'm going to miss this place! The staff at Moore has been incredible; I have to agree with Sarah Levy that the past 12 weeks have been a great learning experience, and one that could have never been replicated with classroom instruction.

Today I sat in on the R.D.'s NICU competency workshop. Typically, our R.D.'s don't cover NICU, since computers do all the calculations for tube feedings, but once in a while a consult will be sent to the office and the clinical director, who specializes in pediatrics, will assess the pt. MRH doesn't have a very high acuity NICU, clearly. But it was interesting to see how calculations would be made, if the need arose. Like Rachael noted, it's a lot more decimals and minute, rapidly changing calculations.

On another note, I saw a pt today, a 89 year old woman who looked absolutely FANTASTIC for her age- I'm not kidding when I say she didn't look a year older than 70, at the most. Well, she was so excited that I came in to see her because it turns out her daughter's an R.D....and a pretty baller one at that: as in, Vice President of Nutrition Communications for a very well known food industry company that shall remain nameless (ahem, HIPAA). She was so proud of her daughter, telling me all about her career path and travels....she wished me luck. She was just the sweetest. I'm telling you, I just love old people. Who would have thought?

One Week Left

2009-07-22T19:31:00.000-07:00

I have started to distribute my perception survey to people in the hospital and I havent been able to get many doctors to fill out a 3 question survey (surprise surprise). For the most part there has been pretty positive feedback from the other disciplines. But i am going to keep trying to distribute them throughout the hospital and hopefully get some more feedback.
The past week has been slow at the hospital even though I have been filling in for R.D.s on vacation. I feel completely comfortable on my own and many of the people on my floors have come to recognize me and talk to me directly.
I have also come to realize that sometimes the role of a dietitian is often therapist. I find that many people I visit want someone to listen to their problems and often are frustrated by eating. I guess I never realized how fixated people are on food especially when they arent allowed to eat or have to eat specialized diet.
That's all for now have a good last week everyone!

Almost done

2009-07-22T13:05:00.000-07:00

This is my second to last day of shadowing before I officially start staff relief on Friday. We just got a consult because a patient has been having really bad diarrhea for the past couple of days (although it's not charted in the electronic record, hmmm) and the nurse today has had to change his diarrhea 12 times. He's already on an elemental tube formula, so switching the formula's not really a solution, especially since he's been on the formula for a week and a half without problems. He's also already getting banana flakes. He only has a couple of new meds in the past couple days and none of them should cause diarrhea. The only other change is that one RD added some Beneprotein a couple of days ago. Has anyone ever heard of Beneprotein causing diarrhea? It seems unlikely but we went ahead and switched him to glutamine anyway. We'll see if that works-- I hope so, for the nurse's sake.

I have done a lot of diabetic diet eds recently-- 4 on Friday alone. The other RDs have been offering them to me for practice, and I actually don't mind because I do need the practice and sometimes end up having good conversations with the patients. Not the guy who was doped up the other day and could only mumble something about candy bars, but most of the other ones have been pretty good experiences. I also got to do a low-purine diet ed on Saturday for a man with gout. I had to break the news to him that he could not cook with Crown Royal and "let the alcohol burn off" because cooking doesn't get rid all of the alcohol, which is of course a big no-no on a low purine diet. His wife was glad that I backed up what she'd been saying all along.

NICU and PICU all the time

2009-07-22T12:53:00.001-07:00

I have absolutely thrived working in the NICU and PICU this week. I love the children and itsy bitsy babies. The NICU is a whole different world to me... a few more decimal points, a lot more numbers, tiny medical equipment, and lots of nipples and milk. The needs of these patients are innumerable. Each case is so unique. Yesterday I only saw 5 babies, and it took the entire day to estimate their needs, change orders, and address other nutrition concerns. One of the aspects I love about the NICU is that the patients always keep you on your toes. Each day babies grow and their needs change. Thus, every patient you see has to be reevaluated and calories and formula orders re-written. I've enjoyed the challenge.

The PICU has proved to be similarly intriguing. We have a few extremely challenging patients whose needs are difficult to determine. At one moment they are gaining weight, then losing, then constipated, then producing emesis, etc. Today I worked on one of these patients for a few hours evaluating his previous needs and TF orders and trying to establish his fluid needs and caloric needs... and talking with nurses, MDs, parents.... I felt like I learned so much with just one case.

With all that said, I think I have found my niche -- pediatrics. I like the challenge and the changes... and the sweet faces.

Rachael

3 days left!

2009-07-22T07:47:00.000-07:00

While I have learned a LOT over the past 12 weeks, I have to admit I'm pretty excited to take my summer vacation. The past 2 weeks at Duke Health Raleigh have been really slow. For example, we've had 10-15 patients to see total (per day), for 2 dietitians and me. And since I function almost 100% independently, it's been like 5 patients per person. Unfortunately it's just a slow time- apparently the hospital goes through trends like this, the summer typically being the time when people manage to stay out of the hospital. It's been nice on one hand to close out my experience on a "relaxed" note, but I think it might get a bit boring if I were an employee here. My CNM mentioned at our last RD meeting that we're not where we should be concerning Aramark's clinical productivity standards. If Aramark decides to start making cuts, labor tends to be the first area they investigate for opportunities to save money. There must be a better way to organize the RD schedule and job structure here, to maybe cut down on labor during the summer months but still have the manpower to cover the floors in "high season", usually the winter months. I don't think my hospital has quite worked out the best plan yet, but I'm confident they will figure it out. The RDs have told me that this summer has been the slowest that they remember.

Anyway, I have to say the clinical experience has been an important part of my RD training. I would never have learned what I did this summer by writing papers and attending classes. I am confident that what I've learned here will enhance my nutrition knowledge no matter what job I end up getting next year. Duke Raleigh has been great, and I'm looking forward to keeping in touch with a few of the people I've met here. Filling out the evaluations this week and receiving feedback from the staff has shown me how much I've accomplished.

I wish everyone luck next week with their last days!

Rex Rehabilitation and Nursing Care Center

2009-07-21T20:11:00.000-07:00

...better known as RRNCC. I'm getting a taste of LTC and rehab nutrition with the RD at RRNCC this week. So far, the experience hasn't inspired me to pursue LTC. This impression may be colored by the fact I've had to learn a different schedule and system for assessments, figure out a completely new system for charting, hunt down paper records from a dozen different places, and circle through the nurse's station countless times trying to find a missing chart. The cases are generally less interesting and less varied, and the brief patient encounters don't add much personality. It is fun, though, to walk out of the office and be confronted by five or six residents aimlessly shuffling down the hall in their wheelchairs. It's a little like bumper cars, and today I witnessed a little chair-rage with a near collision and 4-chair pile-up. Picture it. It's good.

I also had to sit through an overly-long meeting yesterday that could have been reduced to 10 minutes if everyone had been required to watch "Getting to Yes" like I was in Business Management/Human Resources while at Ohio State. Basically, everyone was upset that the RD's at one of Rex's other LTC facilities weren't getting early consults for newly admitted patients, but no one was willing to budge on how to resolve the issue until 45 minutes into the meeting when the real issue came out...that charts are never available because people take them without signing for them.

Human Hairball

2009-07-21T18:39:00.000-07:00

Today, while doing staff relief, I was extremely lucky to get to see the pictures from a patient's endoscopy that showed his sweet bezoar. In case you didn't know, bezoars are like hairballs for people. Frequently caused by medications, hair, or persimmons. Are found in less than 0.4% of endoscopies. Also, in case you didn't know, bezoars are actually magical. I have to figure out what they do: if/how they remove the bezoar and afterwards, who gets to keep it. (If it really is magic, I'd like to be in on the bidding- it's about the size of my thumb!). It looks like a sea urchin with spiny processes that attach it to the wall of the stomach. SO COOL! Maybe I can get a copy of these pics.
I also did a tricky tube feeding recommendation today with an oncology patient who just received a PEG... The chart indicated the patient didn't have home health care, and I was unsure if the MD wanted me to order bolus feeds or continuous feeds, so I called our oncology RD to ask what I should do. She told me that if I order continuous tube feeds, it makes it more likely for insurance to cover home health care, and eventually the home health agency's RD can change the patient to bolus feeds. I ordered continuous and the insurance and home health was set up within a couple of hours. I considered that my major success of the day - only slightly behind actually knowing what a bezoar was before utilizing google.
I saw another patient (84y F) who fell in the parking lot on her way home from church and apparently nothing broke her fall except her face. She looks like she got jumped in an alley. She can't talk or chew because of her multiple facial fractures and extreme swelling and bruising. She could talk long enough to tell me she won't eat eggs because of her Parkinson's medications. Like that should be concerning her at all right now- I just want you to eat some HBV protein, lady!
FINALLY, after a very long day seeing patients, I had the pleasure of setting up and serving food for a Cancer Survivor dinner where they learned about eating antioxidants. After the presentation (by our oncology RD), one 70y+ lady stood up to tell everyone in the audience that she became a vegan 2 years ago and now doesn't eat "anything that had a mother". Since becoming vegan, she says her hair turned from bright white to dark gray. (I'm still very unsure whether or not that is a good sign or bad sign...) Besides the stirring testimony, I don't think she convinced anyone to turn to her side- especially in Gastonia.

ICU and Psych

2009-07-21T18:09:00.000-07:00

I, too, only just realized that I neglected the blog last week! Oops... Maybe because it has been a quieter and tame last couple of weeks at High Point. Like Laura in Asheville, we too have the H1N1 virus roaming about.

I am spending this week in ICU, which is not as interesting as I thought/hoped it would be. Figuring out tube feedings and TPN is kind of fun, but I don't get to talk to any patients since they are all on vents. It has made me realize that I really liked my rotation in the rehab unit and radiation units, as I was able to spend a lot of time with the patients and most of them were very motivated.

I apparently made a friend on the psych ward while I was there the last two weeks. To be totally honest, this unit unnerved me quite a bit at first, not something I am super proud of nor did I expect. I think I just did not know how to appropriately respond to patients and some of the things they would say. After paying close attention to the dietitian I was following and asking her a lot of questions, I started to feel more comfortable. I even made friends with a nice man on the unit who seems to only know me by "Illinois" and continues to ask, "where is Illinois?" this week :-)

Staff relief at CMC Union

2009-07-21T15:15:00.000-07:00

This week I'm doing staff relief. It worked out well for the dietitians because we are down 2 of our 4 dietitians this week. I kind of like being on my own. The patient that has been taking up the most of my time the last two days is a malnourished man on TPN. He also has two stage III pressure ulcers on his back that somehow grew together under his skin to form a tunnel under the skin. I started to feel queasy as the nurse explained it to me. He is still eating po, and I have also been doing a calorie count on him. Yesterday he got about 300 calories and 11 grams of protein. When I go and ask him how he's been eating, he says that he did a good job. I guess that just goes to show that patients might have a very skewed view of what they need to be eating. He is getting his needs met through the TPN, but he won't be able to stay on that once he goes home. I think the doctors might be placing a PEG tube soon. This all raises some of the same issues that Cassie mentioned in her blog. From what I've seen the patient does not seem to want the PEG tube or any of the supplements that I have sent to him, but the family is very insistant. It's hard to know what should be done, especially since the patient seems content to just not eat. In his pallative care report it says that he just wants to go home. It's a lot to think about.
Tomorrow should be a good day for lots of practice because one of the two dietitians we have this week will be seeing outpatients. It will be one dietitian and me for most of the day for the whole hospital - should be fun!

Peds Outpatient

2009-07-21T15:02:00.001-07:00

I am currently shadowing an outpatient peds dietitian. She is also a CDE, and this is what most of her work involves; a few days a week she will see one or two non-diabetes patients. She also has Type I diabetes, I feel like this of course gives her a special edge working with these patients. In the past two days we have seen 3 teens for weight management and one for gluten free diet (she gets a lot of these apparently, and apparently it is very prevalent in children with diabetes too, since they are both autoimmune diseases). The rest of the patients have been diabetes patients, mostly type 1, so most of what she does is with insulin regimens, and not so much with diet. There is diabetes clinic every afternoon and insulin pump training two mornings a week. Today was the training for spanish speaking patients and I must admit it was a little hectic. The lady who was presenting today was a little disorganized and everything had to go through the interpreter (for the parents, all the kids spoke english) so it took about 4 hours. But I now know how to set up a pump and get the catheter in and the tubing set up!

We saw the cutest 3 1/2 year old boy today, and his parents were so on top of his newly diagnosed diabetes, it was inspirational and apparently very out of the ordinary. They carried around a carb counting book and measured all his food on a scale. However, many of the other cases we have seen have been less than inspirational, mostly involving 16-17 year old boys with extremely uncontrolled type I. Today the doctor threatened to hospitalize one patient if he didn't get it under control, his HbA1c was over 14. Yesterday, a boy got his driver's license revoked and DSS was called due to a lack of control over a long period of time. They call DSS if patients can't get it under some semblance of control b/c they are minors and their parents are still supposed to be responsible for their care.

Tomorrow is another insulin pump class, so I'll get even more familiar, especially since it will be all in English...

Back in Acute Care, a New Approach

2009-07-20T20:24:00.000-07:00

I was back in acute care today with a dietitian who has been on maternity leave. It was a slow day, but it was a nice way to ease back into things after having been in Long-term care. It also gave me a chance to become acquainted with her system.

I will definitely learn a lot from this woman. She has a different way of doing things than the other dietitians, and I really liked her methods. They make more sense to me. We have a computer program called VISTA that does the calculations to determine the patient’s needs. However, the dietitian must specify the method she wants and the injury and activity factor to be applied if the HBE is used. Most of the dietitians use the HBE, and you always have to select either 1.2 or 1.3 for the activity factor. This often throws me off because in class we often just multiplied BEE by a single factor (injury factor). The dietitian I was with today uses kcal/kg, which is more logical to me and easier for me to use. I like being able to quickly calculate it and then decide if that estimate seems reasonable. She determines fluid needs by using ml/kcal. I did that occasionally, but usually dosed fluids based on age and weight, per instruction from the other dietitians, except when the kcals needed exceeded the number of mL, then I used ml/kcal. This method is definitely more logical to me under most circumstances.

This RD also uses a slightly different template. The S part of her SOAP note is more of a narrative, and I like the way that it flows. She also does not go through the labor of trying to explain all of the irregular lab values, which initially I thought I was instructed to do. However, I have noticed that the other dietitians do not do it as extensively as I do, and so maybe I misunderstood. With so many possible explanations for the irregular lab values, it is probably better not to speculate.

NICU

2009-07-20T18:29:00.000-07:00

Today I saw the tiniest babies ever -- some weighing only ~600 grams. I spent the entire day in the NICU and realized how much I have to learn about nutrition during this rotation. These little babies have such individualized needs, and the importance of encouraging nippling early in the patient's care is a central nutrition focus. If the mothers are able and willing, breast feeding is encouraged once the infants are able to pass food orally. Many of the NICU babies were on TPN and even more fed enterally (with the smallest feeding tubes ever).

I saw an extremely interesting case today. Baptist, being the largest hospital in the area and having more advanced care than most medical centers nearby, seems to receive the challenging cases and/or the infants with a number of anomalies. Today, I saw a baby with lamellar ichthyosis. This form of ichthyosis is (and I quote from eMedicine) "an autosomal recessive disorder that is apparent at birth and is present throughout life. The newborn is born encased in a collodion membrane that sheds within 10-14 days. The shedding of the membrane reveals generalized scaling with variable redness of the skin. The scaling may be fine or plate-like, resembling fish skin. Although the disorder is not life threatening, it is quite disfiguring and causes considerable psychological stress to affected patients." The prevalence is 1 in 300,000. The infant I saw was a few days old and had a covering of what appeared to be wet saran wrap around her entire body. The dietitian said she did some research regarding the nutrition needs of these babies and said there are no specific needs for them (at this time). She said she is just monitoring the baby like others in the NICU and making sure all of the nutrient needs are met as well as weight gain goals.

More to come. Hope all is well,
Rachael

Making up for last week

2009-07-20T18:19:00.000-07:00

So here I am and I just realized I neglected the blog last week... Thinking back, I think one of the most valuable learning experiences I had was when Mrs. Holliday came to visit. I was able to present my case for her and the rest of the clinical dietitians which was a good public speaking exercise. I was also able to get some feedback and ideas for my paper.

Afterward, the patient that we worked up together was a terminal cancer patient - a man in his fifties. While we looked at his chart, it became apparent that he was probably in his last weeks of life (his white count was 0.7), yet his doctor had him on a cardiac diet. Mrs. Holliday asked me what my opinion was about our role as dietitians in end-of-life care. Now, I have worked up several patients this summer who were in a similar condition as this man, but I realized that this was not something I had thought about in depth. We talked about how when people die it is basically a slow process of malnourishment which eventually leads to the shutting down of organ systems and then death. She explained to me that often, the medical team will stop hydrating terminal patients because at a certain point dehydration leads to a euphoric state for that person.

I ended up going into talk to the patient's wife (he minimally responsive) and told her that they should feel free to make any food requests. I didn't see any reason to put restrictions on a patient in his condition and did my best to be more compassionate toward her than anything. This case definitely gave me some things to think about... what is our role in the care of terminal patients? Shouldn't they be given whatever food they want on the off chance that they actually feel like eating? What would I want for myself or one of my own family members? All important things to consider...

TPN

2009-07-20T08:10:00.000-07:00

Today I was able to bear witness to the creation of a TPN. It was really quite a production complete with: adornment of the full get-up - rubber gloves, booties, gowns, hair covers and face masks, as well as use of hands free door openers, a chemical hood, syringes in a variety of shapes and sizes, and tiny vials of assorted solutions. The entire process took a good 15 minutes with 10 minutes of that going to set-up. After all of the vials were precisely laid out under the hood with the appropriate syringes accompanying them, the vials were checked to ensure that they were consistent with the order. The TPN bag was hung and infusion of the dextrose solution was initiated. Next, the various other components - sodium, phosphate, other minerals, and inuslin were injected into the bag. Once the dextrose infusion was complete the amino acids were infused. Upon completion of this, the bag was checked to ensure the absence of "floaters" aka pieces of cork from the vials that may have broken off and accidentally entered the solution. Finally, the milky white lipid solution was added.

Stepping back from the whole experience I found it really strange that this science experiment was going to be one woman's sole source of nourishment.

Nestle, but no chocolate.

2009-07-18T14:02:00.000-07:00

Yesterday I sat in on my first ever rep demo. A Nestle Nutrition rep came over to the hospital with a luggage sized bag of Panera Bread food to tell all the R.D.'s about the new SPIKERIGHT port for closed enteral feeding containers. After a brief introduction to the product and a summary of the high praises it's gotten from clients, we watched a 19 minute video about how the system minimizes the risk of tubing misconnection errors. It was interesting, since much of the video went over how to connect the feeding tubes to the feeding bags and containers, which really lies on the R.N. to do. It would be a big switch for MRH, since some minimal training would be involved, and since we don't exclusively use Nestle supplemental formulas, which might create some confusion on the floors regarding different feeding tube supplies depending on the formulas....the whole bit took an hour (which I feel is a bit too long considering what was presented to us).

The interesting part was watching one of the R.D.'s, who used to be a Mead Johnson rep, listen to the presentation. She was definitely coming from an interesting angle, and because of her background and business sense, has really been an asset to the R.D. team and our Clinical Manager in negotiating offers, etc. Oh, did I mention this R.D. also happened to be the Vice President of Sales at Mead Johnson Nutritionals less than a decade ago? She's wonderful, too. Can anybody say, networking possibilities? :)

Swine Flu in the ICUs

2009-07-17T18:27:00.000-07:00

Yes, H1N1 has wiggled its way over to Asheville. There are several people on vents in our ICUs receiving Tamiflu. But, do not worry; I have made a big change in my life this summer. I'll admit it to you now (some of you will be extraordinarily proud):

I wash my hands.

A long but satisfactory Friday

2009-07-17T16:50:00.000-07:00

When I got to the hospital today, I discovered that on the floor where I am doing my staffing, there were 19 patients to see. Hmmm... Fortunately several were discharged and one had been seen by someone else yesterday, so I had 13, which was a load for me. I was supposed to go running after work, but I took a nap instead.

My longest case of the day was a gentleman I saw earlier this week who has some sort of vocal cord paralysis/esophagitis/something where he can't swallow correctly so he has to be tube fed for the time being. However, they got him up to Jevity 1.2@30 and he started having residuals of 80-90cc, so they stopped him at that rate. I had recommended Vivonex@85 as a goal rate in case they wanted to try something else that maybe he would tolerate better (I mean, 80-90cc isn't too bad, but they were worried about it, so I did what I could). They kept him on Jevity@30 the whole week. However, today they wanted to send him home, so I got a consult for recommending bolus feedings (which I hadn't done before really), but I looked at his chart and Vivonex@85 was written all over it. Apparently the MD read my note and assumed that was my rec for him at home (which I had made before I knew he was even going home...). So two problems arose. #1 His continuous feeding was not high enough to meet his needs at the moment, so how could we send him home with bolus feedings (which would be 7 cans a day to meet his needs) which he may not tolerate? #2 Would he do better with Vivonex or Jevity at home? He had never been on Vivonex, so how could we send him home with something that he had never tried before with a bolus feeding that he had never tried before either? So I called the doctor (my first time to do that... I'm terrible with trying to figure out the phone system at the hospital...) and voiced my concerns and asked if we could just do a little test bolus of Jevity at the hospital just to see if he would be ok with that. The RD I consulted with told me that Jevity would be a little easier to come by, so we went with that. So the doctor ordered the nurse to feed the patient with 1 can of Jevity (which I watched her do... I had never seen a feeding before, which sounds kind of ridiculous), and the patient did fine. His little wife was in there learning how to do it. So cute. The patient asked me (in his partially vocal-cord-paralyzed voice) if he could use Ensure instead of Jevity, because he likes Ensure because of all the different flavors. He likes strawberry. I'm not really sure where he was going with that. Maybe his stomach has some sort of special taste sensation... Anyways. So the doctor ordered for the pt to get 7 cans of Jevity a day. The doc asked me how to spread them out in the day ("2 in the morning and 5 at night?" was his question... Please. Quite the bolus for a man who has been on slow continuous for a while...). So I shared my recs about spreading them out every couple hours and starting with a few cans a day and work up to 7 just to make sure he can handle it. The little wife was just so grateful for my help and gave me a big hug. I told her I hoped I'd never see her again. (Meaning of course that she would not have to come back to the hospital again....). So a success. I felt my position was an important one in the care of this patient.

Sorry the story was so long. Kind of measures up to my Friday. Have a great weekend, all!

Today's Patients

2009-07-16T20:09:00.000-07:00

I had a few interesting patients today. One gentleman is on palliative care and he has taken a turn for the worst recently. His blood pressure has been very low. After reading all of the chart notes I was expecting to find someone completely uncommunicative. When I walked into the man’s room his wife and daughter were with him. I realized he was a patient I had visited several weeks ago and that I had had a fairly extensive conversation with him and his family. It shocked me to realize that this was the gentleman I had been reading about. It also shocked me that he looked as good as he did and seemed cheerful. He has hardly been eating anything, but said he wanted lasagna, and since we couldn’t provide it for him his family said they would go get some. The nurse offered to heat microwavable lasagna if the family provided it. This patient is also given soda and ice cream, I know he drinks the soda, but I am not sure about the ice cream. Fortunately, I think he does still drink some of the Ensure he is given.

Another patient I had today had recently returned from a short stay in the hospital because of sepsis from a UTI. He also has dementia, so when I went to talk to him it was hard to know how much he understood and how reliable his information was. The other interesting thing about this man is that he is NDD1 and on honey thick liquids. I find it a bit frustrating when I have patients like this because the available supplements are limited. We have a honey thick milkshake that I added to his meals, but you can’t just add an Ensure to provide the additional calories and protein needed with sepsis. He was on IV fluids due to poor hydration status, and his albumin had plummeted from its previous value several months ago, but the sepsis probably had a lot to do with that.

The last patient I worked on today was a tubefeeder. It was a reassessment, as are most of the assessments I do in LTC. He seems fairly stable, but unfortunately he has not been weighed in over a month, which significantly hinders my ability to assess him. I will have to go visit him tomorrow before I complete the assessment.

GMH

2009-07-16T16:41:00.000-07:00

While Amanda was here today, I learned that the rest of you don't have a ridiculous Blood Glucose protocol that triggers a screen of an individual based on their elevated BG/HbA1c in the hospital. I remember thinking the numbers were a bit crazy when I got here, but I just thought the protocol seemed pretty normal- apparently not. We here at GMH see every patient with a HbA1c > 7, any single BG reading >500 (finger-stick non-fasting BG too), and 3 BG readings > 100 (finger-stick non-fasting and/or AM CBCs).
As Amanda pointed out today, this creates a ridiculous amount of work because most individuals in the hospital will have 3 BG readings > 100 at some point in a typical 4 day hospital stay. In fact, if you arbitrarily checked my BG throughout 4 days I guarantee it's >100 often. Additionally, seeing these patients with mildly elevated BG d/t stress, medications, simply being in the hospital doesn't actually advance or improve the patient's status, its just putting your hands in extra pots. Amanda pointed out a very interesting management perspective that visibility does not equal job security - especially in the days of EVIDENCE-BASED practice and EVIDENCE-BASED reimbursement and EVIDENCE-BASED everything. I think she's correct and I also think that if you have/are a manager who tries to extend the RDs into screening individuals who are at low risk, this actually can hinder their appropriate care for the higher risk individuals. I mean, nobody wants more work, but when the extra work is pointless and is also decreasing the level of care provided for patients who need you, it's not good for anyone.
Tomorrow I get to be creative in the morning and work on a handout/brochure for another chef/dietitian demonstration, which is good because I'm really starting to miss the creativity in this job!

A "Carolyn moment" at Rex

2009-07-16T15:44:00.000-07:00

Well, I think you all knew that I couldn't make it through the summer without one glorious moment of unparalleled klutziness. That moment came today. It seems like they refinish the floor of one unit each week at Rex - they strip off the shiny coating with a horribly chemical-smelling liquid, lay down a new coat and buff it until you can see your face in it. They try to be unobtrusive by only doing small sections of half of the hallway at a time, but they still block doors for quite a while. It can change your plans for the morning if they're working right outside the patient rooms you need to visit. Well, today I decided not to be deterred. I had to get into the supply room to pick up some formula for a patient. They had put up the caution ropes but hadn't started waxing yet, so I brazenly walked into the supply room. I delivered the formula with no problems. Then, on my way back, I noticed another RD with an arm-load of formula cans (a pt had rejected all of the Vivonex we sent her to drink PO...can't blame her). So instead of making her hop the caution ropes with all of those cans, I decided to do the hopping for her so that she could just hand me the cans. I took just one step over the rope, and I was on the floor. Totally on the floor. My pager and calculator went clattering across the newly waxed linoleum. There was a collective gasp and then silence at the nurse's station. I assured everyone that I was OK and assured the wide-eyed maintenance men that it was entirely my fault. As I got up and carefully made my way back to ground with coefficient of friction >0, a nurse seized my lab jacket by the collar so that I wouldn't fall again. (She later told me that she was worried I would take her down with her if I fell again, and then she might break a bone because she has to take Boniva.) Everyone asked if I was injured about ten times, and the manager of Environmental Services had to come talk to me. Then I had to go to Employee Health and fill out a variance report. The nurse asked, among other questions, "do you know why this incident occurred?" to which I replied, "Is 'stupidity' one of the options?"

Getting back to actual dietetics...end-of-life issues continue to fascinate me. The cat man made it out of ICU with an alb hovering ~1.6. I had an opportunity to speak with the surgeon, staff nurse and palliative care nurse about him yesterday. Apparently, his wildly metastatic gastric cancer had caused such an extreme bowel obstruction that he was vomiting large amounts of stool. The surgeon thought that even though the prognosis was poor, that was no way to die, so he operated on him, forming a fistula between two remaining viable portions of his intestines. Now, after his good long stay in ICU, the pt is back on the floor and actually eating. However, he still "has cancer like someone spray painted his insides with it," in the words of the surgeon, and he still can't eat much. The pt maintains that he wants to be a full code and have everything done, but he doesn't seem to grasp the severity of his condition or the complexity of his care. (His thinks that his neighbors could look after him just fine.) His daughter stands by what her father wants. This leaves us in an awkward position because he can't eat enough PO to meet his needs, but the surgeon doesn't want to put a feeding tube in such a diseased GI tract, but a nursing home won't take him on TPN, but the pt doesn't want to die, which is what would happen if we stopped TPN, but the pt thinks he's getting better and wants to go. The saga will continue through the weekend with a calorie count...

Georgetown Week 10

2009-07-16T15:41:00.001-07:00

This week I am on my last rotation - GI/Surgery. I like GI. I've seen pts with bowel resections and even a pt with a DIEP facial graft, etc.

One of the pts had exploratory laparotomy and an OSH which resulted in a stomach perforation. She was transfered to Georgetown, and her abd has been huge, round, and distended since she came in. She was started on TPN because of the perf. After it was fixed, she was started on trickle feeds. We attended medical rounds, and the teams said she was handling the TF well, so we asked to slowly increase TFs and DC the TPN. Well, 3 days later, the pt was STILL on TPN, even though we very clearly discussed it with the team. Apparently, one of the new residents was worried that the pts albumin was a little low, so he decided TF and TPN together (both providing full nutrition) would be a good idea. OMG, crazy. Sometimes they really just don't get it. I checked again today, and I saw the pt was NPO for some procedures. There was no TPN running today, but that same resident ordered TPN for tonight. When I asked him about it, he said it was just for the meantime since she's having procedures today. I tried to explain that we normally don't order TPN for just one day. And, even if we do order it, by the time it gets here (we put orders in by 11am, and they come in at 8pm that evening) her procedures will be over. I still don't think he understands!

A lot of the dietitians are in and out of the office, using vacation time, so I've been seeing pts on my own and helping out.

Peds Clinic

2009-07-15T18:18:00.000-07:00

I spent the day in the outpatient pediatric GI clinic today and loved it! The RD who I was with was problem-solving all day, so that patients can actually implement the nutrition care plans that she or another RD had come up with. The most striking example was one delightful 5-year-old girl with autism who hadn't grown in a couple of months. Mom said had her G-tube feeding almost entirely because she was eating so well. In fact, her dietary recall showed that she was eating enough to meet her estimated nutrient needs. However, it obviously wasn't enough for growth, so the RD suggested that she run tube feeds overnight. Mom said she would, but then Grandpa jumped in and said "Didn't you stop the tube feeds because you found the tube wrapped around M's neck one morning?" Apparently she moves a lot in her sleep and is not verbal enough to call for help if she did start to choke. This totally legitimate concern would probably have prevented mom from actually running the TF overnight. So we came up with a new way to bolus the formula to meet her needs, avoid overnight feeds, and not be too inconvenient. This little girl will be back in a few months so we can see how it is going.

The stories are still super sad: a baby who tested positive for cocaine at birth and has possible fetal alcohol syndrome, 2 ex-24 weekers with cerebral palsy, etc. But these kids seem like the lucky ones who have caregivers who are taking them to appointments and doing the best they can to meet their needs.

SICU/CTSU

2009-07-15T18:16:00.000-07:00

WakeMed SICU

It has been unusually slow since I started at SICU, however, when I came back from weekend, it became a trauma unit on Monday. Therefore I need to assess all the patients, evaluate their needs, even before surgeries. My preceptor said to me: Welcome to my world. It was not bad on Monday, I finished on time, learned for trauma patients especially head/neck trauma, we need to push medical team to know of their nutrition needs, and important for their prognosis.

We had tele-seminar on nutrition support for ICU patients. APEN guideline for EN and PN just came out recently. There are a lot of things differ from what we learned in class! Such as:

Obese patients need to be hypocaloric feeds in ICU (22-25 kcal/kg of IBW), however, Protein need is much higher compared to normal size patients, (Patient with BMI over 40 even need 2.5 g/kg protein of their IBW).
For EN: it has been widely accepted Tube feeds should be on hold if residuals over 200 ml, however, from this seminar, it is not good indicator for GI tolerance due to other input, gastric volume, lying position etc. Paper said TF may be on hold for residuals over ~450 ml. It is not what they practice in clinical setting.

I have been working independently from last week, which I really want to do, I appreciate my preceptor trusts and it gave me more room of learning and practice.

There are only two weeks to go for summer; time goes fast than I image. I will start to do staff relief from tomorrow!

Basically, we’re all educators.

2009-07-15T16:06:00.000-07:00

Yesterday and today I spent the day at the outpt diabetes self-management center. Interestingly enough, I arrived Tuesday to find out the two full-time R.D.s were going to be working from the health department and hospital, so they weren’t going to be at the center all week, and I was to spend the days with Lynn, the R.N. at the center. She said not to worry, since her and the R.D.s were “cross-trained” so they all performed the clinical and nutrition assessments on incoming clients. Hmmm. Interesting. So I observed the R.N. complete the nutrition assessment on a few clients; thankfully, all of whom were strangely self-motivated and in good-standing health despite their recent diabetes Dx.

The center was different than I envisioned. It was very small considering the size of Moore Regional, and the amount of referrals this place got. Two R.D.s, one R.N. and an administrative assistant run the whole place (since the two R.D.’s were out for the week, the R.N. and administrative assistant were the only ones in the office). Classes are provided several times a week, and program participants are scheduled to come in and attend 10 total classes to graduate from the program. The classes cover everything from foot care, meal planning and physical activity.

Today the center was going to do an educational presentation at the senior community center, so Lynn asked if I’d like to give it. So I spoke with a group of 20 seniors about Diabetes management and prevention, and general meal planning and nutrition. It turned out pretty good, actually, and I got a lot of good questions at the end that I was actually able to answer :).

Tomorrow Lynn arranged for me to meet up with Jon, an R.D., CDE and a former dietetic intern who ended up staying in the area. He’s working from one of the other area hospitals doing diabetes ed stuff, so I’m interested to see how that differs from what the inpt R.D.’s do and what the outpt center does.

Endoscopy

2009-07-15T14:50:00.000-07:00

I spent this morning in the Endoscopy Suite in the hospital watching EGD's and colonoscopies. I probably would have been fine seeing only one of each, but they had me stick around for a while and watch a bunch. Basically they do some preventative colonoscopies, and then referrals for patients with GI issues. A 72 yo guy had 9 polyps removed from his colon, so it was good he came in for a screening! Most of the other patients had diverticulosis, so it was interesting to see. The doctor told me that when he talks to these patients after the procedure he recommends Fiber One cereal, and then doesn't address any other dietary issues. When I asked him what he tells people who don't like Fiber One , he looked at me dumbfounded...apparently he has never had that issue before??? When we started chatting about foods with fiber in them, he seemed shocked and amazed. He thought that you would have to eat 30 bowls of oatmeal a day to get enough fiber!!! I tried to tell him about different foods with fiber that he could tell his patients to eat, but also threw in a "You could always refer them to a dietitian" and he seemed like he might actually consider it. He then also told me how he had JUST found out that soda had a lot of sugar in it...so the fact that this doctor is giving nutrition advice to patients kind of scares me!

Talk about allergies...

2009-07-15T13:57:00.000-07:00

This week I've continued my staffing of the oncology/medical floor, which I've thoroughly enjoyed. I've had a lot of good patient and family member interaction, and I feel like I've made a good impact on several people. One little wife of a little old man told me that she really liked having students help her husband. Some nursing students had been there before me, and she told me they were as caring as they could be. She was really grateful for my consideration of her husband's wishes. So cute.

However, I happened upon my most interesting patient of the week today. I thought it was just a normal diabetic education for a middle aged man who couldn't learn how to control his glucose very well. I looked at the chart where the MD wrote the orders for a RD consult, and it said "Nutrition consult--allergies." Nothing about diabetes... I go in the room, and the patient is asleep. However, there is another man in the room (I think the patient's brother...), who was happy to see me. It was he who had asked the doctor to ask for a RD consult. Apparently the patient had stomach stapling performed during the 1970's, which caused some complications, and he had to have it reversed. In the process of these complications, the patient developed "allergies" (supposedly...) to: all meats, poultry, seafood, green vegetables, and strawberries, along with some medications. The patient also has CKD, diabetes, CHF, CAD, HTN, etc. His brother told me he follows a diet of primarily grain-based carbs (chips, biscuits, cereal, tortillas), vegetables (which only included corn, pre-soaked potatoes, and KETCHUP--yes, he said that), eggs, bacon, and the occasional piece of fruit. He had a semi-working knowledge about foods with potassium and phosphorus. He said that his brother is usually in the hospital about once a month. They just moved from Washington, and the RD at their old hospital took care of them all the time. So I was trying to figure out what kind of diet to put him on... vegetarian + renal + diabetic + cardiac + no allergies? Awful. I ended up printing out a menu for the next 3 days and having him fill out what he wanted. The brother filled it out for him and basically wrote in that he wanted cereal for every meal, with a piece of fruit, and 2% milk (milk three times a day = phosphorus, anyone?). I gave him some handouts about K, Phos, and carbs, but who knows if that education will do any good. Who knows. A bit hopeless.

ICU

2009-07-14T20:13:00.001-07:00

Yesterday was my first day at the ICU. It's a whole different world up here! (ICU is on the top floor at the VA). The day started slow, with only 5 patients. The RD suggested that I could go cover other floors, but she spoke too soon. By the end of the day, there were 15 patients on that white board at the nurse's station. Crazy!

One of which was a home tube-feeder, coming from a city in Northern CA 4 hours away from the SF VA. When we got to calculations, he was only receiving 1500ml of Promote w/ Fiber daily @ 125 ml/hour, with no po intake at all. I was surprised that he wasn't losing weight, since it doesn't meet his caloric needs. And 125 ml/hr seemed too high a rate to be tolerated well. What's amazing is that his albumin is 20, and his skin has no signs of ulcers whatsoever. Confusing. But hey, if he's healthy, then that's good (and he is pretty healthy; he was at the hospital to get a Baclofen pump replacement). So we changed the TF recs to 70 ml/hr x 24 hours, and updated his wife on changes and additional instructions on how to check for gastric residuals.

On Carolyn's post, I've seen a lot of patients with C. diff at this hospital (maybe because they're mostly older men?). The RD I was working with at the time gave C. diff patients some Activia for probiotics as an MNT, but that's about it.

I also saw a modified barium swallow today. It was neat!

History/ Wanting the uncertain Future to be History

2009-07-14T20:05:00.000-07:00

I got a history lesson from one of my patients today. He told me about opening the gates of a concentration camp in WWII. It sounded pretty amazing.

I finally got the information about the wounds I needed (discussed in previous blog) and fortunately they are healing. However, as I was writing up the patient’s assessment I began to doubt how I had decided to classify him, and I will need to speak to the RD tomorrow. I enjoy getting to know the patients in long-term care, but I am finding it difficult to let go, and to accept that I will not be around to reassess them, nor will I be around to check on them between assessments. The latter makes me a bit nervous. The moderates are re-evaluated every 30 days, but I think the mild pts are reassessed every 90 days. That is why I am doubting my initial impulse to change this patient from moderate to mild. The issues that made him moderate before, albumin and wounds, have significantly improved, but as I looked a bit deeper his DM is very uncontrolled and his renal function is quite poor. He is overweight, but the classification of his weight status is a bit nebulous depending on whether BMI or target body weight is used. Normally BMI is used, but I believe I was told at one time to use TBW when assessing patients with an amputation, and another time I believe I was told you could consider both and then use clinical judgment. Anyways, I am a bit preoccupied with this patient at the moment, and I will be glad to talk with the RD and get him finished tomorrow!!!

I have to remind myself that many other health professionals are monitoring these patients, and that the dietitian will be told if a patient’s health status changes. Also, the Diet Tech and RD DO check on the patients regularly at meal rounds, so even though there is a lot of time between formal assessments the patients are being watched in the interim.

MNT for C. diff?

2009-07-14T19:42:00.000-07:00

I was caught off guard today at ICU rounds. The RD was held back dealing with a pt on another floor, so I went alone, pretty much expecting to take notes and report back to the RD. We got to one of the pts we've been following - a woman with ARDS whom we put on Oxepa over a week ago. In the midst of reviewing her condition, the nurse throws in "and we need to give her more fiber because she's developed some diarrhea." The MD adds "yeah, I think she has C. diff. How much fiber is she getting now? can we increase it?" Fortunately I knew her MNT order and that Oxepa has 0 gms fiber. I was shocked, though, that fiber was the first thing that everyone thought of to manage C. diff. Has anyone else ever heard of this? Has a fiber-free formula ever given anyone diarrhea? Unless they think the lack of fiber has caused good bacteria to die and C. diff to take over...At any rate, the RD and I had looked up C. diff info yesterday for another pt, and we found that management is basically "left to clinical judgement" since there's no solid data on effective MNT. Fortunately for me at that moment, everyone decided to wait until the cultures were in and her meds reviewed more carefully to make a decision. I'm still not good with making clinical judgements on the spot.

Another instance today of relying on clinical judgement, and a very sad case: an 89 yo woman was discovered in her home by the police. She had suffered a massive stroke. The last time someone had contact with her was 4 days prior, so it's hard to say when it happened. I was consulted because she has 10 pressure ulcers (stage II & III) from lying on the floor for so long. She also has ARF and severe rhabdomyolysis (a term I never thought I'd see again after NUTR 620...but she wasn't a licorice-eater). She has severe dysphagia now as a result of the brain damage, so she's a strict NPO. It was hard to know what to tackle first - protein for the pressure ulcers? weight gain? or is she underweight d/t dehydration although she's had a day of IVF? decrease protein for the ARF? will she have refeeding syndrome? have her intestines atrophied? In the end, I don't think it will matter - I think she's bound for hospice, which is probably the best decision. So I left a recommendation for Jevity 1.5 Cal, 4 cans/day, bolus feeds as tolerated, with water flushes of at least 60ml/feed, or to exceed UOP by 500 mL - if consistent with the plan of care and family wishes.

Let me sprinkle some of my magic dietitian fairy dust....

2009-07-14T15:17:00.000-07:00

Today I counseled a woman on weight loss. She said she had been trying to lose weight since around age 9, she was now in her 60s. She had tried everything. And apparently she wanted me to perform magic on her, since she was determined to lose weight, while still eating most meals and either, Little Cesars, Bojangles, or KFC. It was very frustrating but also one of my favorite experiences this summer, since I talked to her for about 45 minutes about things she felt frustrated about and what she would be willing to change. Since I am interested in outpatient counseling I think, it was a fun experience for me. Her friend was there, and she was helpful, she kept reminding the patient how important it was for her to be healthier, regardless of whether she lost a lot of weight or not, which I thought was a good point to focus on as well.

I think one thing that really helped her was a book I gave her, it tells all the nutrition facts for most fast food chains. I really think she just didn't fathom how many calories were in what she was eating. We decided that she would start keeping a food diary and start using the book to count up how many calories she was actually eating. Unfortunately, since this was inpatient, I won't get to see her again, which is sad to me and why I want to do outpatient, so that I can development a relationship with patients, like Bridget mentioned. Hope everyone's week is going well!

An MPH will serve us well

2009-07-14T13:34:00.000-07:00

hey everyone!
Im in outpatient peds this week, and the clinic that I'm with is a low-income population. Most of the kids are on WIC, a lot are spanish speaking, and im pretty sure everyone is medicare. Anyways, I feel like for the first time in this summer rotation, I have found the public health aspect (rather than the strict dietetics aspect) of our program really useful. Ive sat in on multiple talks about infant formulas, talked to a lactation consultant about breastfeeding vs. formulas, heard a lot about the healthcare reform ideas, and mostly I have talked a lot about WIC. The pediatritians in the office write the "WIC prescriptions" for the baby formulas, and most of them consult the RD if the baby needs to be on any hydrolyzed-type formula. The RD has also taught me a lot about the changes to the WIC packages which will reduce the amount of formula that moms get if the baby is breastfeeding + formula feeding. She said they are trying ot cut back on "los dos"- which is the clinic's term for "topping the tank" when moms breastfeed then "feel like" the baby didnt get enough, so shove a few more ounces in the mouth of formula. Basically taking away all of the satiety clues, etc, that are brought about through exclusive breastfeeding.

Ive also learned a lot about the changes to Enfamil formulas (the NC WIC formula). The Lipil (basic formula) now has a prebiotic in it to emulate that which is in breast milk and is now called Enfamil Premium. The Enfamil Nutramigen, which is the elemental formula used with cow milk allergy, now has a probiotic in it which is supposed to help the gut to heal from the inflammatory response caused by the cows milk allergy. So obviously we all advocate that breast is best...but if the mom wont do it, its important that we stay on top of the formulas. And this RD really knows her stuff.

She does counseling on obesity and FTT, as well as is at the call of all the residents in the peds programs. She does a lot of their education, making sure that they know all of the formulas so that when mom asks the pediatritian (as every mom does...) about formula or feeding then they know the answer, or they have her to pull into the room. She has a really cool job, and its been interesting to have heard a lot about WIC from our program and be able to discuss the changes with her. So my point is that there are jobs out that which would combine clinical with a little public health, and I think we would all be perfect for those type positions!

Cystic Fibrosis Clinic

2009-07-14T12:55:00.000-07:00

Today I spent the entire day working with one of the pediatric dietitians in the CF clinic. It was certainly a change of pace relative to the inpatient setting, but I enjoyed the casualness. While we only saw 4 patients, our appointments consumed all of our time. Each patient required very individualized nutrition care regarding varying doses of pancreatic enzymes, nutrition educations (salt, fat, etc.), etc. At times I felt frustrated because it seemed like there was not a "black and white" way of providing nutrition guidelines. There are definitely nutrition guidelines available for treating a CF patient, but even so... each case is unique and those guidelines seem far too general to apply to all patients. After the day, I had a more accurate understanding of the demands of treating CF. The lives of these patients appear to revolve around their disease. Talking with the families and the patients opened my eyes to a lot in the world of CF.

I also had the opportunity to observe a Pulmonary Function Test (PFT) -- a test used to evaluate the function of the lungs based on the ability of the patient to take in and release air. The patient was on continuous oxygen support, and it was evident she was determined to do well on the test. Her test results were great! I loved seeing her eyes light up as she watched her results appear on the screen. Neat to observe.

Loving peds so far! Hope all is well,
Rachael

PEG placement

2009-07-14T11:40:00.001-07:00

I finally was able to witness a PEG placement this morning. The decision to place the PEG was a fairly controversial one for the elderly women who received it. She had a will drawn up in 1988, in which she had indicated that she was not interested in "aggressive" nutrition therapy. Currently, the patient is mildly demented and unable to convey her wishes and help us out with the interpretation of "aggressive." She has been here for nearly two weeks and hadn't been able to take anything po. While the hospital would normally interpret her will to mean no PEG, her daughter (the POA) feels differently. There have been two ethics committee meetings involving the family, and finally the decision was made to place a PEG.

The patient seemed very uncomfortable during the procedure. She is unable to verbalize or communicate at all, but she spent most of the prepping period moaning whenever someone touched her in any way. The procedure itself was fairly brief. The patient was put at ease, as best as possible, and given some mild sedatives. It was really interesting to see the inside of the GI tract through the endoscopy. I was surprised at how clean and smooth this woman's esophagus and stomach were considering her age. Once the stomach was located, an incision was made into the abdominal wall, the PEG tube was fed through the mouth and brought out through the incision site, and secured into place. All in all things went fairly smoothly.

The case really made me consider what my wishes night be if I ever ended up in a similar situation. I still have yet to reach a decision on this.

What can I say? I like oncology too!

2009-07-13T17:36:00.000-07:00

( I just had to steal it )
Today was day 1 of my Oncology mini-rotation and the Oncology RD at GMH has a pretty cool job, where she spends part of her time covering the inpatient Oncology wing and the other part with patients from the outpatient Radiation/Oncology Center. The ROC at GMH is, for lack of a better word, gorgeous. It gives you the warm fuzzies and makes the patients feel comfortable. The chemotherapy treatment rooms overlook a garden and lake and the walls are filled with artwork. They have free beverages (anything you could imagine- those $4 bottle of bolthouse farms juice, etc) and a "Look Good, Feel Better" room with free wigs, scarves, along with offering free massages and manicures one day a week. The patients and staff seem to develop awesome relationships and they know their patients all by name. The staff and patients seem to celebrate successes and endure difficulties together, and while cancer is a mean and terrible disease if I ever have to deal with it, I hope I can be lucky enough to treat it at a place with such committed people as this. It is a completely different looking and feeling place than what I remember going to when my grandma was going through treatment.
While I like oncology, I guess what this day really solidified to me about my career preferences and future job search is that I need to find a job where I get to work with the same patients and develop some type of a relationship- so it's probably going to have to be outpatient.

Outpatient ed

2009-07-13T17:26:00.000-07:00

Today I had an outpatient education for a child who was 3 years old and was allergic to just about everything (gross exaggeration but kind of true). She was allergic to fish, peanuts, soy, wheat, corn, apples, oranges and few other random things. I had a really hard time preparing for her visit because everything I wanted to suggest to this little girl was something she was allergic to. Pretty much she can eat meat except fish and fresh fruit and vegetables minus the apples, oranges and corn. The only education I could really offer the mother was to teach her how to read the food labels, give her a list of ingredient names that may be misleading and tips for foods that are acceptable. I felt as though I just kept repeating that she just needed to read the food labels. It was frustrating not to be able to help anymore than that but she seemed to think it was helpful. The other issue is this particular mother was enrolled in WIC so she is also limited it foods that she can buy and on a budget so specialty made foods may not be an option for her. Hopefully this little girl grows out of these allergies because she wont be able to eat anything really that isnt raw. Otherwise things around here are pretty calm nothing new and exciting. Just diabetes and TPN.

My Case Study Patient

2009-07-13T15:58:00.000-07:00

So, I have been following my case study patient for about 3 weeks now,and the last time I see her will be Friday, before I leave New Bern. She has been in the hospital for 4 weeks. She is definitely an interesting case. She came in with abdominal pain, and they did an exploratory laparotomy, and found her sigmoid colon to be perforated from severe diverticulitis, so they had to resect it and make a colostomy. They also found an incarcerated ventral hernia, which is where the contents of the abdomen protrude through the abdominal cavity and into the abdominal wall, through weak spots in the abdominal muscles. It is incarcerated when it is unable to be pushed back in. All the blood supply was cut off to the area so the parts of her small intestine that were in the hernia were ischemic and had to be resected as well.

She went from tube feeding/clear liquids to TPN all of a sudden a few weeks ago, and it took me a while to go through the chart to actually find why. Turns out they believed she either had an obstruction or an ileus post surgery. From what I can tell, it was proven she had neither but the TPN was never discontinued, despite 2 notes to the doctor from me and one from another RD, since the patient was able to eat orally during this time period. Hmm. Then her wound dehisced (when it breaks opens along the suture line), so back to the ICU with her. So it has been an interesting journey. She just ripped out her NG tube, so we'll see where her diet goes from here...

heart cath

2009-07-13T14:28:00.000-07:00

Today I got to see a heart catheterization. It was very interesting to watch. I was thankful for the nurse that was watching the X-ray screen with me because if it weren't for his explanations I would not have known what was going on. One of the best parts of the procedure, however, was talking to the doctor beforehand. He was very interested in nutrition. Since he's a cardiologist, he recognized the important role of prevention and nutrition in heart disease. He went on and on about how important it was, and it was hard to get a word in! I told him that I was always glad to meet a doctor that valued nutrition. He recommended a movie called Food, Inc. Anybody seen it?
We had two very interesting teleconferences on hyperglycemia and wound care last week. They emphasized that blood sugar control is critical for wounds to heal. This was interesting to think about because we often give a protein supplement to patients with wounds. I wonder if the supplement is a waste of money if their blood sugars are out of control. Like Sierra, I too have been wondering about how to care for wounds in patients with renal insufficiency. There was one protein supplement (Juven) that the teleconferences said was safe for renal patients because it was recently reformulated to remove the potassium, but I am going to research it some more because it seems like you would still need to count the protein in it. I'll let you know what I find sierrra :)

Ice Cream

2009-07-13T14:26:00.000-07:00

I'm working the oncology/pulmonary floor, the Oaks (the psych hospital), and Cape Fear Hospital (a small, cushy hospital that mostly deals with ortho) this week. Working the oncology floor is very different than working in the outpatient cancer center, since the patients are much sicker. On Friday, I actually saw a patient I'd educated in the outpatient center. She looked very different, a month later. I actually didn't recognize her-- her mother recognized me and I, in turn recognized her mother, but I would never have recognized the patient out of context. Cancer sucks. I try to fight it by offering to send everyone ice cream but the patients aren't always up for a sweet frozen treat. So instead, I sent this patient fresh fruit and beef broth (her requests). It's not going to fix her severe pain episodes but it's the best I can do, since I don't carry morphine with me.

I also saw a couple of adorable geriatrics today at Cape Fear. I wanted to hug them both and feed them pudding. The man was raving about his lunch (with bits of salmon sprinkled on top of his shirt, since the bibs at Cape Fear, unlike at his nursing home, aren't very good) and proceeded to discuss his favorite dessert--strawberry ice cream with blueberries--and the fact that at his SNF, he gets a PBR every night after dinner: "it puts you right to sleeep!" The woman was just cute as a button (and as tiny as one too). She's determined to get her weight up (she says she's going to try to drink 3 CIBs per day, instead of the two she drinks at home) but assured me that my weight was fine. I had been worried and had been about to ask her opinion of my weight, so that was sweet of her to say...

2009-07-13T10:15:00.000-07:00

I spent the last week doing general staff relief and seeing a little bit of everything. Doing lots of diet eds and seeing interesting patients while trying to go a little quicker and get my patient numbers up for the day. That's been a challenge for me- moving faster through the prepping and charting (and our charting is quite extensive and somewhat inefficient) so that I can see more people. I think I've been making good progress on this, until last week when our census was way down and there just weren't enough patients to go around. Looks like that's been resolved as of today.

Couple of interesting things from last week... I worked on Saturday to get a feel for what a weekend was like here. On Saturdays the general plan is 2 RDs, and only new high risk patients are seen. We don't set up any follow-up assessments for Saturdays but we will see Monday follow ups if it is slow. It was a pretty mellow day but we did get to see a couple of traumas.

I went in to do a DM diet ed for a patient last week, who turned out to be an old friend of my father's. So that was awkward. I guess that's the trouble with working close to your hometown. Speaking of home, there's a lot of homeless people that come into this hospital-- is anyone else finding that to be true? Sometimes diet eds are ordered from the MDs, which I'm finding very difficult to do with this population.

Hope you all had a good weekend! 3 weeks......

Goodbye, Nursing Home

2009-07-12T13:45:00.000-07:00

Last Friday marked my last day at the CLC (Community Living Center, or the nursing home), after 3 weeks. I did not expect to have enjoyed working at a long-term care facility as much as I did. I enjoyed it so much (I commend Amanda for preparing me with everything I need to know about working with older adults). At the CLC, assessments are more scheduled and I feel included as a team member alongside the MDs, RNs, CNAs, PTs, OTs, social workers, and recreational therapists. I also enjoyed getting to know the veterans, and their families, better than in an acute setting.

Three of my patients passed away last week. One was a hospice patient with a massive tumor in the abdominal area, whom I had seen for an initial assessment last week. Another was a tube-feeder, already in a pretty bad shape when he was transferred from the ICU just a few days ago (I did get to do the calculations for his tube-feeding and talk to his wife about feeding him for pleasure). And last but not least was my case study guy, a renal & diabetic patient whom I saw as an inpatient when he was getting a BKA, then as a hemodialysis patient. He had a pretty complicated life in the social aspects as well (his wife has dementia and his son passed away a month ago). I am sad. I think I had grown slightly attached to him.

More on working with older adults, I did some education for a guy who has hyperkalemia and "brittle diabetes," which if I remember correctly, is a type of diabetes with episodes of hyper- and hypoglycemia (very unstable). It was also interesting because he had suffered from TBI previously, so he has some cognitive impairment. He seemed to be compliant, but who knows if he can retain all that information.

Although most of the veterans at the CLC are all sweet, and I mean sweet little old men, there have been some difficult, grumpy old men I had to see. In particular, I had to see one who was not satisfied with the meals that he's getting (he has a long list of standing orders because he doesn't like anything). I think he lectured me on how the VA's food service system could be more efficient than the present for about 20 minutes. Fortunately, I was able to escape from his room by making some compromises around his foods and ensuring him that I would take his points to the supervisor. I was glad to have difficult patients as they do exist, and it was good to practice working with them.

3 more weeks of clinicals! I hope you all are enjoying your experiences!

A week of observations

2009-07-11T17:09:00.000-07:00

I squeezed in a lot of observations this past week: a PEG placement, a g-tube being exchanged for a low-profile PEG, a dressing change on a deep wound with surrounding bedsores, TPN compounding, and indirect calorimetry. In between all of that, I helped the nutrition support RD to do lab checks on all of the TPN patients, write and change TPN orders, and assess ICU patients.

I like the environment in the ICU - it seems like the care is coordinated a little better due to the severity of the cases, and nutrition is viewed as an important part of patient care. The MD called us out for being 5-10 minutes late for rounds and proceeded to catch us up on the patients we needed to see. One patient we had already been following - he has been inpatient since early May but was moved to ICU this week. It's a sad case: an 70-something man got severe N/V on the day of his late wife's memorial service. They discovered he had metastatic gastric cancer, and he's been in the hospital ever since. He has coded 3 times, but he and his daughter still want everything done. He is mentally with it, but his body is just about gone. His albumin was 0.9 after his last lab draw, and he's even been getting TPN for weeks. The MD said his chances of leaving ICU with alb that low are just about zero, but this pt has surprised him before. In the words of the MD, he must be a cat because he seems to have nine lives.

Renal and Pressure Ulcers--What do you do with Both?

2009-07-11T16:46:00.000-07:00

I am in the process of revising my renal module, and I have seen several pts recently with poor renal function. Often times CKD is just a background condition, and something else is the current focus of medical professionals. I am sometimes a little unsure how to proceed when pts have a history of CKD or renal insufficiency, or labs that suggest poor renal function. Sometimes when I look at their GFR history I see a lot of fluctuation. Do these pts need to be on a protein restricted diet? How feasible is it to restrict protein in the diets of pts in long term care who have access to other sources of food? Also, how does such a restriction impact their quality of life? Their other health conditions?

On the other end of the spectrum, I have also seen patients recently with pressure ulcers and wounds, or with a recent history of them. I am having a hard time understanding how serious some of the wounds are due to the confusing chart notation. I spoke with the RD I am working with and she agrees that the notes are confusing. I spoke with some nurses who were partially able to clarify, but the one nurse I really needed to speak with was off on Friday. What do you do with patients who have pressure ulcers and a medical history that includes CKD? I think my chances of encountering such a patient are high given my current rotation in LTC. I have been reading about pressure ulcers and kidney disease, but I have not read anything about which takes priority when a patient has both. If anyone who reads this has encountered such a patient please send me an email.
Thanks!

Case study and Peds

2009-07-11T15:28:00.000-07:00

Hi everyone!
These weeks just fly by before I get the chance to post on the blog! I wanted to update everyone on my case study- to refresh, she has drug-induced fulminant liver failure and has been in the hospital since May 19th. Shes on the transplant list (and has been in and out of the ICU because of encepalopathy) but she had sepsis and an infection and they had to put her on hold on the list until they got that cleared, but on Friday she got activated again! My fingers are crossed that she gets a transplant very soon! I present on Wednesday, so my presentation will be more on the progression of her liver failure, but I thought I would share a general outline of what has been going on. First, she was dietiting when all this went down so she was really not eating much upon admission because of that. Then, she got very encephalopathic and was placed on a hepatic formula. Then, they let her go entirely po again, but she stopped eating well so she was put on Jevity. She then went into acute renal failure so was placed on Nepro, and then she had emesis and was unresponsive so they intubated her. Then They put her back on Jevity but her blood glucose was running high, so now shes on a diabetic tube feed! She has had quite the course, and on Friday I evaluated her and her K was high, so we were thinking she might have to go back on Nepro over the weekend! Shes trying to eat a lot po as well, but her prealbumin was 6 last week regardless of the amount of protein and Kcal that we KNOW she is getting through that tube (granted she has severe ascites...they did paracentesis last week and they drained 5.8 L. SERIOUSLY?!?! Anyways, Im just working away this weekend on the presentation and having a hard time figuring out what to focus on because she has had SO much happen to her. She needs to get a liver fast or she could rapidly decline...so stay tuned!

I was in Peds last week and loved it! The RDs at CMC write the TPNs, and so I have started to get a hang of writing them in the adult world, but the peds world is an entirely different ballgame. They use completely different forms because they base the dosing on mEq/kg rather than mEq/24 hours. This is because the littlest ones change weight every day, so it makes it easy for the dietitians to play with the ratios while also compensating for the weight change of the babies. I think that Peds (as Laurie and Sarah have said) is a place where dietitians are really respected, and the CMC ones do a great job. They have dietitians who work in the outpatient metabolic clinic, the nephrology clinic, and the GI clinic and these women have very frequent contact with their patients and families, whether its when they come in for dialysis every week, whehter they are in and out of the hospital, or whether they write their new TPN orders every week...they have a lot of respect. very cool to see.

enjoy your weekend everyone!
Elizabeth

Drug rep encounter

2009-07-11T13:54:00.000-07:00

This past week has been a pretty slow week at High Point. I am seeing rehab patients, psych patients, radiation patients, and anything else that might come up. There are simply not a lot of patients right now.

I did have an interesting encounter with a drug rep while I was following a dietitian in the Diabetes Center. Several conflicting studies have raised some concerns about a particular insulin. One study showed an increased risk in cancer compared to 2 other versions of insulin. Other studies showed no increased risk. The drug rep came by the center to "alleviate" any fears that any of the dietitians or physicians may have concerning their drug. Now, I realize that not all drug reps are "bad" nor do they fit the stereotype. But I hate to say that she very much fit the stereotype. She had all of the research studies with her to give us, but she made it very clear that she was not supposed to do so (and thus, was basically doing us a huge favor and showing us that they have nothing to hide). Nevermind that these studies are published in peer-review journals that we all have access to and quite easily. She was quick to rattle off all the negatives and "invalid" aspects of the main study in question, yet she was not able to answer any of my questions related to study design, models used, or outcomes measures. Granted, she admitted to not being an expert in epidemiology and did say that she could give us the contact name and number of one of the research specialists at her company to answer my questions. But still, in order to tout the pros and cons of a study, she should know a little more, I would think.

It was definitely a bit fishy....

Peds

2009-07-11T13:28:00.000-07:00

I started my pediatrics rotation this week – it is a whole different world. Like Laurie said, I really like the respect that dietitians get from the pediatricians. The other major plus, in my opinion, is the rapid feedback from our MNT interventions. The baby gains 40 g in a day, her ezcema clears up in a week, etc.

The major downside is seeing sick little kids with bad social situations - which was about 75% of our patients. Some was benign cluelessness, but too much of it was caregivers who for whatever reason were not adequately addressing their kid's needs. I struggled as much with my anger and sadness about that as I did with pediatric needs assessment.

Highlights of the week was a follow-up of a 6 month old FTT kid with a vegan mom. Mom was breastfeeding, but the baby was very underweight for his age. There were a number of possiblities for his malnutrition, including inadequate intake, poor quality of the breast milk, or malabsorption, and it turns out all three probably contributed. The RD who saw him initially immediately suspected it was a food allergy, because the baby had severe ezcema and his siblings had food allergies. The MDs thought it might be a milk-protein allergy and put him on a soy formula, which made his ezcema even worse. The weekend RD was consulted and recommended that they try him on an elemental formula (100% free amino acids) and d/c breastfeeding. They did, and when we saw him again, he had started gaining weight and his ezcema was vastly improved. He was able to go home at the end of the week. Mom's breastmilk was analyzed (and Mary Rose Tulley was consulted!), and it turned out to have half the protein that breastmilk normally has. Having learned that breast milk quality is not usually affected by nutritional status of the mother, I was pretty surprised by the lab results. It makes me worry about mom, especially since she really didn't want to formula feed her son and was going to try to cut soy out of her vegan diet. Eeek! I wish we could have provided some nutrition education for her, but for some reason we didn't/couldn't.

We saw a 4-year old who hasn't really grown since he was 2 years old, which was around the time he became a super picky eater who wouldn't eat anything except pizza, fries, chips, and OJ. He had been even been seeing a pediatrician regularly, but the lack of growth went uninvestigated because Mom and Dad were short. Uh..... He didn't even come in for FTT, though, but for unexplained edema and vomiting. They ran dozens of labs and tests to come up with a diagnosis (discovering in the process that his micronutrient labs were bad), but his condition is still unexplained. However, he does like the Resource Breeze juice box we gave him and was started on a multivitamin, so hopefully he'll start getting the nutrients he needs. I feel like that is a bandaid on the more serious problem of his disordered feeding behaviors, but my RD pointed out that the feeding behaviors is not something we can fix in the hospital. We did request a speech consult to assess the picky eating, and the ST gave the parents some tips to try to improve his intake.

A good week

2009-07-10T16:47:00.001-07:00

I've been on my own all week covering the oncology floor, and I've really loved it. Maybe not the floor necessarily, though most of the patients are really able to communicate with me and the nurses are all very helpful, but I enjoyed being on my own completely (except for running around trying to find an RD to sign all of my notes...). But I would have to say my favorite experience this week was Wednesday went I spent a day with a doctor in the NICU. I absolutely loved it. This doctor said basically his whole job was nutrition, trying to get these babies to grow. I feel that I like this segment of the ICU as compared to adult ICU for a couple reasons. #1 Though the patients can't communicate with you (similarly to other ICUs), their parents are always around to talk to and encourage. I love not only providing medical aid, but also the direct encouragement to families and patients so that they know that a medical professional is looking out for them. #2 Though about 98% of the patients are getting some sort of nutrition support, compared to adult ICUs where the patients used to be able to feed themselves but now are in a terrible medical condition, the little babies have never been able to eat on their own. I suppose it's more the beginning of life need for nutrition support than end of life/advanced disease/etc. need for it that I enjoy. However, a sad story, we did have one preemie baby with ESRD (I suppose that term still applies... that's what a PA said, but who knows). At first, they gave him a relatively high calorie formula to help him grow (he was probably about 1 kg or so), but his BUN and Cr were extremely elevated. So they cut back a little bit with a less dense formula, but his growth started to plateau. So they increased it again... BUN up... etc. They can do acute peritoneal dialysis on babies only when they get to 2 kg, and they can transplant kidneys when babies are 10 kg. The baby just has to make it there first. Also, the parents have to decide if they want their child to be undergoing dialysis for an indefinable time period, which would obviously not be a pleasant experience. So, a tough place to be in. Poor little guy. I'd give him a kidney.

Anyways, great experience though. 3 weeks to go! Also, Sarah and Diane, my case study is coming to see you guys for a doctor who specializes in intestinal motility. She may potentially be on TPN for the rest of her life (she is 32) if he can't help her out...

Second to Last Week at Craven

2009-07-10T14:58:00.000-07:00

I can't believe that I'm almost done working at Craven. Today one of the dietitian's was off and I took over her floors. It was so super busy but I got it done eventually. One of her floors is Oncology and I have to say it is my least favorite unit I have worked in. I feel like there is very little we can do for the patients that I have seen here. That may be because it is inpatient and not outpatient. One man I saw today was actively in the process of dying and on comfort care so there was nothing we could do, he couldn't even drink water without choking. Another man was wasting away and wouldn't eat or talk. I do feel like I helped one lady who just got a PEG, I managed to find a supplement that she really liked and would be willing to drink in addition to her PEG feedings.

One of my favorite areas has been the ICU and Surgical Floor, because despite the really sick and sad situations of many of the patients, I feel that our nutrition support recommendations can really help out the patients. One thing this summer that has really frustrated me though is the lack of communication between disciplines in the hospitals. There are no rounds meetings except in rehab and it is hard to gain comprehensive information on the patient from the charts. Nurses get very frustrated trying to talk to everyone that has questions for them because of a lack of interdisciplinary communication. I was surprised to find that even the ICU here does not have rounds, but my RD and I have been working on a project, aimed at designing a checklist and format to start interdisciplinary ICU rounds due to some clear communication problems that have emerged.

What can I say? I like oncology

2009-07-10T13:44:00.000-07:00

(Yes, Cassie, I stole your title :)

I just got home from spending the day in outpt oncology. What an incredible day. I’m still trying to nail down just why it piqued my interest so much; I never anticipated enjoying this unit so much. I know it has a lot to do with the oncology R.D., Gayla. Gayla is fabulous at her job. She works in oncology 3x/wk and in the hospital working floors like the rest of the R.D.s the remaining weekdays.

To start off, oncology isn’t nearly as depressing or hopeless as I thought it would be (my dialysis unit could more accurately be described with these adjectives). Gayla has a great relationship with the nurses, doctors and radiation therapists in oncology, and they’re all --without exception as far as I could tell-- quite the positive bunch. You have to be. They joke and tease and check in on each other’s pts, and it really creates a welcoming working environment. As I was leaving this afternoon, one of the doctors called me aside and told me that the key to medicine is having a good sense of humor, and he added at the end that that was why they liked Gayla so much.
I think one of the other reasons I was attracted to the oncology unit is that the R.D. gets to follow up with pts over a longer period of time (throughout the extent of their treatment), and thus really gets to develop a longstanding relationship with these individuals. I met a few such cases today. One of Gayla’s old pts (from 3 years ago) was admitted to the hospital for pneumonia. We went in to check in on her (even though Gayla wasn’t covering the floor she was on) to see how she was doing. Over the course of yesterday and today, we checked in on the pt 3x. The woman has been on a TF for the past 3 years because she can no longer eat anything PO. For the rest of her life. Gayla says she’s never even complained about this and has handled everything really well. Anyway, we went up to her room and Gayla about sat down on the bed to talk with the pt. She involved the pt in her own care and asked her what she’d prefer, so in the end we changed her TF from bolus to continuous, and then to a formula with more fiber to help with some of her GI issues. Gayla then went as far as to talk with the Case Manager about her recs for her discharge TF and what company the pt usually went with and then with the attending to let him know about her TF change and if he could possibly put in an order for some IV Fe the pt needed since her low Fe levels had been overlooked. When rounds were over I was just impressed with how the R.D. went about everything so as to be an asset and not a nuisance to the medical team. I mean, she basically made the Case Manager and M.D.’s job a little easier by mediating on behalf of the pt.

Whew. Anyway, we met too many interesting pts that I wish I could see again. It was not a dull day. I also had the opportunity tour the E.D. and observe a PEG placement!....And tomorrow will be my first weekend day working, so we’ll see how that goes!

What can I say? I like diabetes

2009-07-09T17:40:00.000-07:00

So today my preceptor asked me to see a 17-year-old boy who came in with DKA from his type 1 diabetes. We had received a consult for diabetes education. Now, first of all, CRMC is certainly not a children's hospital. This was the first time I have had to talk to a patient under the age of 30 during the entire clinical experience. Anyways, before going into his room I took a look at his chart and talked to his nurse. I found out that this boy has had diabetes since he was 2 years old and is in somewhat of a rebellious phase of his life. His nurse was really stressed out because his doctor had ordered an insulin drip, SSI, a D5 IV, and a 2800 calorie diabetic diet (kind of ridiculous). She had been chasing his blood sugars around all morning and seemed to be pumping the insulin into him. When I went into the room I was able to talk to his mother (he was sleeping) about his struggle with his disease. I decided pretty quickly that they probably knew just about everything I would normally tell someone in a diabetes education session for an inpatient. What she really needed was for someone to talk to her about some ideas to encourage attitude change in her son. I told her about CRMC's diabetes center and their great CDE staff, my experiences at camp, and about speakers that I have seen this summer with Type 1 that have been sponsored by the hospital. I guess it wasn't exactly the most traditional education session, but I'm pretty sure that when I left she felt better, and I think in some situations that is probably the most important thing.

Georgetown Week 9

2009-07-09T17:18:00.000-07:00

Today was my last day in Oncology. The RD gave me one of her floors, so I was pretty much on my own today.

I had one consult for a woman with peritoneal CA, who requested to speak with a dietitian because she has lost about 24 lbs since she was first diagnosed. She basically wanted to know what to eat to start gaining some wt. It was a bit challenging because she says she has a milk allergy, it's not just lactose intolerance. We talked about nutrient-dense foods, and sneaking in calories with honey, peanut butter, nuts, oils, gravy, etc. We also discussed making shakes with soy milk and supplements, especially because she gets full very quickly. I provided some handouts from NutritionCareManual.org.

I saw two pts that are bascially going downhill. One was started on TPN because she has a partial SBO, and he's only on clears right now. He is not a candidate for surgery and it is likely that they won't start chemo either. So basically, there was no other option.
The other pt has stomach cancer. He is on a mechanical soft diet, but he also gets full very quickly because of a stomach resection. He just had an abd CT which also showed a bleed (I was confused about why he's allowed to be on a diet), so GI says he's not a candidate for a J-tube at this time. He also has liver mets, so pallative care is hesitant for TPN. We had rounds today and most people, including the medical team, think this case will probably end up with hospice since we're running out of options. But, the pt doesn't want to give up!

On a different note, I saw a f/u Psych pt today, on my own. We see pts on this unit by consult only. She is a vegetarian and initally wanted to talk to us because she feels that our kitchen is "not equipped" to provide appropriate vegetarian meals. She says the vegetarian meals do not consistenly have enough protein. The kitchen says they are sending her what shes ordering - grilled cheese, salads with cheese, and beans, but she says she doesn't get what she orders. So, I don't know. I asked the kitchen to give me a copy of the vegetarian menu. Last time we recommended soy milk, yogurt, and peanut butter with all meals. She's been getting these things but is sick of eating the same things over and over again. Understandable. I requested a PAB check.

More ICU Shenanigans

2009-07-09T12:11:00.000-07:00

Today I worked alone in the cardiac ICU. I have been missing the patient contact/conversations, because all of my patients have been intubated/sedated of late. Today, however, I had the opportunity to talk with all of my patients (except for one). The first patient created a bit of commotion in the ICU. I was talking with him (and he apparently was very confused) when the doctor walked over. I introduced myself to the doctor, and he asked me why the patient had received a clear liquid tray. I told him an order had been placed for it on the 7th, and he proceeded to tell me the patient majorly failed his FEES on the 7th and should not be eating/drinking at all. Subsequently, the doctor walked over to the patient to explain that he should not be eating and would have to take the tray away. The confused patient was not too fond of this idea. He looked upset then raised his fist in a ball and said to the doctor, "I am going to punch you if you take my tray." The doctor informed the patient that would probably not be a good idea. The patient kept shaking his fist and the doc smiled at me, and we waited in awkward silence for about 2 minutes (painfully long). Then the doctor said once again he would have to take the tray. The patient must have forgotten in the mean time his previous anger because he said ok and off went the tray. Funny story.

I also presented my case study today. It went very well, and I feel like all the dietitians learned something (hopefully). I talked about perforated marginal ulcers as a complication of roux-en-y gastric bypass surgery. Fun stuff.

Tomorrow is my last day in the ICU... then off I go into the world of pediatrics! Hope all is well.

Rachael

2009-07-09T07:35:00.001-07:00

Yesterday I got to spend some time at Duke Raleigh's cancer center with one of the dietitians that works here. I enjoyed being off the floor and seeing something different. What Heather (the RD) does on a regular basis is much more specific; she sets up her day by seeing who the "new starts" are on the schedule, and noting when she is able to squeeze some time in to talk to them. I accompanied her on a few patient interviews. Some were in to receive only radiation, and others were receiving combination treatment- both radiation and chemotherapy. The patients seem to value their time with the RD. They often have many questions, and Heather can help figure out individual strategies to increase their intake. They commonly report that they either have no appetite or altered taste perceptions. The RD hands out nutritional supplements to help the patient decide what tastes best to them. I enjoyed my time in part because cancer is a disease that nutrition truly plays a very important role in managing. There is much evidence proving that preventing weight loss in cancer patients improves outcomes. I liked the counseling environment too. Instead of feeling rushed in and out of patient rooms in the hospital, these interviews were relaxed and under no time constraints. And most of the patients are very receptive to the education, and sometimes just value having another person to talk to/listen.

GMH

2009-07-08T15:59:00.000-07:00

I can't believe I only have 4 more days with an RD until I'm completely on my own for the rest of the internship. I've been finishing up with the Nutrition Support Dietitian this week, but our census is pretty low, so I've been doing projects and different things here and there. I did a test tray this morning- which was actually really difficult because I don't usually eat a hot, greasy, filling breakfast that early in the morning and the smells in the kitchen were making me pretty nauseous. The rest of this I'm working on some fact sheets and recipes for some cooking demos we're doing in the hospital cafeteria.
Hopefully I'll get to go back over to NICU with that RD this week- everyone says it fills up around the full moon (which is tomorrow, in case you were wondering).

QI results

2009-07-08T15:52:00.000-07:00

I finally finished getting all the data for my QI and it turns out only 46% of the time do the doctor's actually follow the suggestions of the dietitians. This seemed really low to me although not that surprising. I am in the process of developing survey questions about how other disciplines (mainly dr) perceive dietitians. I am having a hard time keep it short because one questions leads to about 5 and everyone knowns docs have about 30 seconds before they are on the next thing. So if anyone has any questions they think might be good I would love some feedback.
Other than that not much is going on at the hospital. I had my first patient with PPN yesterday and today there were 2 more. When it rains it pours here. Thats all for now. Hope things are going well for everyone!

On my own

2009-07-08T15:01:00.000-07:00

I have been taking over a few units by myself now and screening the floors when I get there and seeing patients which I am excited about! I had an interesting experience today with a patient follow up. We had seen him two weeks ago due to being on dialysis and we educated on a renal diabetic diet. When I saw him today, he and his wife were so excited b/c the few times he was on dialysis here had miraculously "cured" his kidneys and his function had returned enough for him to stop dialysis! So they were super excited and motivated about following the renal diabetic diet! It was exciting, since two weeks ago they had been so forlorn. I feel like they see this as a second chance in life, to be healthy again.

Amanda visited me today and we worked through a really interesting patient! He had esophageal cancer a while back and had a resection with gastric pull up and a j-tube to feed him. However, recently his j-tube had become dislodged without the family really knowing much about it, he came into the hospital with a BMI of 15 with a dx of malnutrition. So turns out, the doctors discovered a large amount of enteral feedings floating around in his abdominal cavity area and it didn't go into his intestines at all! Yikes. So some new recommendations were formulated for his NG tube that will hopefully go in place tomorrow! Fingers crossed...

Long term care

2009-07-07T20:32:00.000-07:00

As I mentioned I am in long term care at the moment. I went to a treatment team/ care team meeting today. There is a stark contrast between the treatment meetings in LTC verses those in acute care, and I think one of the biggest contributing factors is the role of the MD.

In acute care the representatives from the different disciplines gather and then wait until the doctor is ready to see them. The doctor updates the group on his/her patients and leaves. Then the next doctor is called to repeat the process. Occasionally the doctor seeks advice or asks how things are progressing with respect to other aspects of the patient’s care, but the MD is definitely in charge and does the majority of the talking. The dietitian I followed to these meetings almost never said a word in the presence of the MD, though sometimes we talked with the pharmacist afterwards.

In LTC the MD is only occasionally present at the meetings. There are representatives from nursing, RT, Pharmacy, dietetics, social work, PT? OT? Etc. The nurses sometimes run the show, but everyone seems to be on an even playing field and the dietitian seems more involved. It seems more like a democracy and less like a dictatorship. Even when the MD is present in the meetings he/she seems to hold less authority.

I do not mean to be critical in any way. There is nothing wrong with either approach, and I guess the meetings do serve different purposes. I am simply pointing out the differences that I have noticed. Some people probably like one style and some prefer the other, but it has definitely been good for me to see the different styles of collaboration.

I previously mentioned that they spend a lot of time getting LTC patient’s meal preferences right. This makes sense seeing as they are there for an extended period of time and it is their temporary or permanent home. Along with this comes the issue of patient’s rights. How much freedom should patients be given in terms of their access to food? Some patients do not have the mental capability to remember when they last ate; others have trouble controlling their impulses, and may hoard the snacks. What snacks should be available to all patients for free, and what should be available in vending machines if they choose to purchase food? What about ordering pizza? These freedoms, and the social living environment in which some patients give food to others, make it difficult to control some of the medical conditions. This kind of environment can lead to unwanted weight gain and uncontrolled diabetes. Where do you draw the line between providing the best treatment and allowing freedoms which may enhance quality of life?

Bariatric Center brings it.

2009-07-07T19:07:00.000-07:00

For the past two days I've been working with the R.D.s at the Bariatric Center of Excellence here at Moore Regional. There are two full-time R.D.'s at the center, and they cover all of the bariatric pts that come through the center. There are two surgeons that perform all the bariatric surgeries here, and I've had the opportunity to observe both of them in the O.R. One of them, Dr. Mitchell, has logged over 1,000 bariatric surgeries in his career! (And he's not even that old!)

Anyway, after sitting in on a few 2 week post-0p pt follow-ups, I attended a 3 1/2 hour class led by one of the R.D.s and one of the surgeon's nurse practitioners. The class was held for pre-bariatric surgery pts who were already a few steps into the process of preparing for surgery (which included a psychological test, consult with the surgeon, etc). The class was very informative, if not a bit overbearing. The R.D. and N.P. covered everything from comorbidities to the 3-step post-bariatric diet to the very regimented maintenence required after discharge from the hospital (feeding through your G-tube to supplement intake, drinking blue powerade and checking your Blake tube for internal leaks, sipping on fluid 10 hrs a day, tuning in to new hunger cues, etc). To be perfectly honest with all of you, I left the class feeling entirely overwhelmed and utterly thankful to have a normal BMI and functioning GI tract. To be even more honest with you, I felt like driving straight to a cookout after the class and ordering an 800 calorie milkshake!

Anyway, yesterday when I was at the bariatric center, I was able to do a few fun things like get a full body composition test and indirect calorimetry/metabolism test done. I won't share my body fat % with you guys, but my metabolism was apparently in really good shape (not a shocker). The R.D. waived the $90 fee for this test (because you know I wouldn't have put that money done for the test!)

Tomorrow I'm back in DaVita for my last Dialysis day. (fyi: DaVita.com has really good recipes for dialysis pts!)

Laparoscopic Cholecystectomy

2009-07-07T14:57:00.000-07:00

Today I watched my first ever surgery, a lap chole. The sight of the doctors puncturing the skin and the smell of burning through the flesh both made me uneasy. I was glad I was sitting down. I was also glad they never had to open him up. The part that I saw on the screen was cool though. It was neat to see the liver, gallbladder, small intestine, and fatty tissue so clearly on the screens. If you've never seen a laparoscopic procedure, the doctors stick two little instruments through the side of the patient's midsection. The instruments have multiple purposes such as holding, scraping, and cutting. The surgeon was very skilled at manipulating them and using them to gently cut away the gallbladder. After cutting the gallbladder away and tying off the cystic duct, the gallbladder was free and somehow made it out of the tiny hole in the patient's abdomen. I'm still puzzled as to how it squeezed out because it happened so fast that I missed it. Overall I have no desire to go back to surgery anytime soon, but it was an interesting procedure and a good experience!

Cape Fear-Week 9

2009-07-07T13:21:00.000-07:00

Hello all. This week has been the beginning of my two weeks of staffing on the oncology floor (which also has some random other types of disease states as well...). I'm definitely liking being on my own a lot, because I can work at my own pace (which is still pretty slow compared to the other RDs). The part of oncology that I don't really like too much is that most of the patients will never get better, no matter what you do, which is kind of sad. But I do what I can for them. For example, a patient today who was a young guy with sickle cell (not really cancer, but still on that floor) said he had been in too much pain to reach the food that was sitting on his bedside table. I just wheeled the table right on over next to his bed. He asked if he could give me a hug because he was so thankful that I did that for him. (I thought a handshake might be more appropriate.) Just little things make people's day.

Also, I get to shadow at the NICU tomorrow morning! The bad part is, one of the nurses up there just got diagnosed with swine flu... Frequent hand washing is in order.

Hospital Craziness

2009-07-07T11:31:00.001-07:00

This is my second week in the ICU. These past few days I have been working in the neurosurgery and trauma ICUs. Quite interesting and sad. The stories are unreal, and I continue to be amazed. Most of the patients are on a vent and enterally or parenterally fed. Perative seems to be the formula of choice in these units. Patients come in all shapes, sizes, ages and genders... although I must admit the majority of the trauma patients seem to be men. Hmm. Maybe their wild sides could not be restrained any longer?

I learn more and more each day. In fact, on a completely different note, I was working on my case study earlier and found out some unexpected info. My patient is s/p Roux-en-y gastric bypass surgery (in 2002) and arrived at WFUBMC with a perforated marginal ulcer (x2). Well, I originally estimated her needs using her ABW because she was 150% of her IBW. However, after speaking with the Bariatric RD, she said she would have used the gastric bypass standards of care to estimate her needs --> 14-22 kcal/kg IBW and 1.5-2.0 gm protein/kg IBW. The results were quite different than mine. However, my patient had been eating a higher calorie diet prior to admission and also had additional energy needs due to her recovery following 2 operations, etc.... it made me think she needed more than the meager 763-1200 kcal estimated using the gastric bypass standards. The Bariatric RD did say that each case is different and independent variables must be considered for each patient. Complicated I tell you.

Cannot believe we only have 3+ weeks remaining. Time flies.

Hope all is well,
Rachael

Georgetown End of Week 8

2009-07-06T18:59:00.001-07:00

I started Oncology on Thursday of last week. It is definitely a different atmosphere. We hear alot about hospice care and code status - some pts are DNI/DNR. The RD mentioned that it is tough on this unit because she really talks to her pts and gets to know them, and then some of them die. We were working on one pt and the RD got really frustrated because this pt was barely getting any nutrition currently, and generally hasn't been eating very well since he was diagnosed. She was like, "Now they consult me? When it's too late!" She really feels, and I agree, that nutrition needs to be addressed ASAP with cancer pts. It surprised me that MDs can forget this, some of these pts are clearly wasting away, we need to feed them!
The energy needs depend on the type of cancer, stage and mets, but its seems like in most cases we give about 30-35 kcal/kg, and 1.2-1.5 g pro/kg.

I've been working on more TPNs and talking with pts on PO diets. They use a lot of supplements in these units and we try to sneak in calories however we can. Everything from Beneprotein in soups to peanut butter. One pt said he liked soft, soothing foods, so we called down to the diet office and asked for ice cream and puddings.

I'll be in Oncology all this week.

Surgery/Neuro ICU

2009-07-06T18:24:00.000-07:00

I can't believe I have been in ICU for 3 weeks, still at least two more weeks to go!

Based on my schedule, I will spend half of my internship in ICUs-- WakeMed has very specialized ICU, therefore I am be able to see complicated cases, and get along with Clinicians with different specialties.

This week, I am be able to start/follow up two TPNs with my preceptor. She gave me the space to think, critize, make my own decision for adjustments, then shared with her. We have standard forms for TPN, which used for hospital wide only few months a ago. We still write whole progress note for TPN adjustment, which is the longest note I have ever written! It is great, kind of summerize all the findings, clinical progress, as well as plan changes.

I am still practicing, become more and more independent!

Start reading previous medical records for my case study, very huge!

Cautionary Tales

2009-07-06T16:48:00.001-07:00

For the past few days, I've been shadowing the dietitian who does the GI and post-surgical floors and the surgery/trauma ICU. It's definitely been the most challenging rotation so far-- these patients are very sick and very complicated, medically and nutritionally. We did a followup on a patient today following his indirect calorimetry test--turns out he needs 3300 kcal a day, which is just mindblowing considering he's intubated and doesn't have a head injury. Yes, he weighs 500 pounds and has been in the ICU weeks as various organ systems shut down in turn, but still...

One of my favorite parts of working in the hospital is hearing all the crazy stories about patients. Today one of the consultants told us about a couple of recent patients he'd seen: The first was a man (I'm not sure his age) who decided it would be a good idea to let a friend light a firecracker (a small one) while it was in his mouth. Something went wrong after it was lit and he ended up swallowing it. Somehow, it did not explode his throat or gut, but all the fumes given off went into his lungs and messed them up something awful. He may or may not survive... Yes he had been drinking.

Another guy was having a reunion with some old college friends with whom he used to snort cocaine. He doesn't do coke anymore, but didn't want to have to fess up to his friends, I suppose, so he raided his wife's stash of Splenda and snorted that instead. Turns out that if you look at Splenda under a microscope, it looks like little balls studded with spikes. Not good for your lungs and nasal mucosal membranes. Everytime he sneezes his nose bleeds and he's having some other problems as well.

So in case anyone was considering doing any of these things, don't!

CRMC last week...

2009-07-06T16:31:00.000-07:00

Okay, so this blog is actually for my activities last week since it turned out to be such a busy weekend. It was one of my favorite weeks so far. I am finally feeling really confident reading charts and finding information in a timely manner. Most of my week was spent working on cases involving GI disorders and nutrition support. At CRMC, there is one pharmacist that does all of the micronutrients for the TPN and we work on the macronutrients. I had several opportunities to work with her to initiate and adjust several TPN formulas. Today we checked up on a lot of those patients and she walked me through the process of adjusting electrolytes and ordering new adjustments. This was a good lesson and hopefully I will get more chances to work with the macronutrients, as I'm sure other hospitals expect their dietitians to be able to do this!

Also last week, I was able to sit in on an Ethics Committee meeting. This was interesting. Although no nutrition topics really seemed to come up, an attorney employed by the hospital gave a presentation about discharge planning, gaurdians, and living wills. This turned out to be helpful in understanding the decision-making involved in healthcare and the legal processes involved. Committee members from several different disciplines were able to add to the discussion and provide their own experiences with this.

Nutrition Support Error

2009-07-06T16:16:00.000-07:00

This morning the RD who worked the weekend asked the RD I was working with today and I to check on a patient that she had left a nutrition support recommendation for. She had received a consult over the weekend for nutrition support. The consult was for PPN, so she calculated the appropriate rate for PPN and left a recommendation. When we looked at the chart this morning, he was receiving TPN at the rate that had been recommended for PPN!!! This was about 3500kcals for a man who is 71" 137#, so very clearly above his needs. We hunted down the nurse to talk to her about it, and she told us that his blood sugar had been well over 500 since the rate was increased on his TPN. We were able to track down the MD, and got her permission to write an order to change the rate ASAP to something more appropriate for his needs. Nutrition support was recommended because the patient hadn't been eating for quite a few days. We were really worried about the possibility of refeeding syndrome. The first thing we worried about was his Mg and P levels, and tried to check his labs, but the Mg and P levels hadn't been checked for the day. We are planning to follow up with the pt first thing tomorrow and make sure his blood sugars have normalized and that his Mg and P levels are alright.
It was amazing that a rate like this could have actually been started on a patient. Not only did the recommendation clearly state that it was for PPN, but pharmacy is supposed to be checking behind the MD whenever they order TPN or PPN. The nurse also didn't track down the MD right away when she saw his blood sugar levels up in the 500s. Luckily we caught it within a day of it being started, but it obviously could have been pretty disastrous for this patient. One of the RDs has been trying to start a nutrition support team at the hospital, and I think she just got another example of why it is really important to have a lot of eyes checking and double checking on nutrition support.

Nutrition Support at Rex

2009-07-06T15:33:00.001-07:00

I finally started working with the Nutrition Support Dietitian (she's a CNSC). I was feeling a little behind since everyone else has been calculating EN and PN prescriptions for weeks, but I've only made a few EN recommendations. I was nervous going into today since I hadn't really brushed up on TPN calculations since MNT refresher. (It was 4th of July weekend, after all...) It turned out surprisingly well, though. It all came back to me like riding a bike. The CNSC was impressed that I could actually calculate a new TPN prescript on on my first day. (I think she's used to dealing with pharmacy interns who aren't nearly as well prepared.) It was fascinating to learn about all of the things you have to consider when setting levels of electrolytes, insulin, etc. One new fact: ICU pts are frequently given meds that decrease peripheral circulation, which can lead to falsely low accucheck readings, so you have to be careful when assessing blood glucose readings to adjust insulin. I really like that nutrition support is very analytical, but there's still an element of intuition. I think I'll miss patient interaction, though.

My first wound and wound-vac change:

2009-07-05T08:54:00.000-07:00

I had my first wound viewing and wound-vac change experience last week. It was quite possibly the most unbelievable thing I have ever seen. The female patient, in her early 40s, had a wound from her last cesarean 18 years ago that never healed. She had an 18 yr old wound! She weighs over 300lbs and has type II diabetes, both of which have compromised her ability to heal the wound. She has seen several doctors about it over the years, as it would get infected, get worse, then treated, get better, then worse, etc. But it has never fully closed. Thus, the surgeons at High Point decided operate on her last week. They basically cut open her abdomen from hip to hip (and mind you, on a 300lb individual, that is a very large/long incision) and removed an incredibly amount of infected tissues (I think there was more there that was infected than they were expecting). They basically removed everything they could down to her organs.

Before going into the room, the wound nurse cautioned me that this is a very large wound and it could be a difficult one to see as a first. I braced myself as we entered the room, but nothing could have prepared me for the way it looked. In all honesty, it was more fascinating and very surreal than anything. This woman's stomach, from hip to hip, was completely open and exposed. Even more incredible is that she was in very little pain considering her condition and that, if all goes well, the wound would be completely heal in 3 months! The whole concept of a wound vac I also found intriguing; I mean, who thought of stuffing a wound full of foam, sealing it up, and sucking the air out?! Kind of crazy, if you ask me, even knowing that it encourages tissue to regrow. Still.... kind of crazy!

Although not in great comfort, it was good to see the patient in high spirits despite her condition and all that was going on. Still, I cannot help but wonder about her ability to heal this wound, now even larger, since she was not able to heal the original wound. Obviously, she now has more careful care and more people involved in helping her to heal this wound. But if she is unable to keep her blood sugars under control and continues to be protein malnourished while at home, how will this wound ever completely close?

Random tidbits from Salisbury

2009-07-04T17:13:00.000-07:00

Between puffs of a cigarette a patient told me he likes his blood sugar between 200 and 300. I didn’t really know how to respond. He obviously has his own ideas about his health. He has always been very pleasant when I talk to him, but I have heard and read notes suggesting that he is not always so angelic. I don’t think he would be very receptive to education.

I spoke with Laura yesterday, and it made me excited to get back to Chapel Hill and to hear about everyone’s experiences. I think we are all having very different ones. An example of a difference is that there are 4 ICU’s at Laura’s hospital and mine only has 6 ICU beds! I haven’t seen any trauma patients and I do not think that I will. I don’t get the sense that the VA has many. I am spending the next two weeks in long-term care and definitely will not see any there. It was also nice talking with her because she gave me some useful education tips. I am definitely struggling with my patient educations.

Yesterday I worked on my Special Project, which is to help the VA transition to the NCP. I have been assigned the duty of drafting a NCP Note template for them to use for their Comprehensive Assessments. I have been talking with a few other ladies about the project, but yesterday was my first attempt at actually creating the template. We use templates for almost all of our notes, and the VA currently uses the SOAP format for their comprehensive assessments. It was very quiet at the hospital yesterday, but it was nice to be able to work without interruptions.

Dental Advice

2009-07-03T11:40:00.000-07:00

This is rather off-topic, but 100% health-related.

A UNC dental student has befriended me, and while some homemade pizzas were baking on Monday night, I asked him my teeth questions. I think I should pass along these two tidbits:

1. The best toothpaste is apparently Colgate Total. I was told, many times over, NOT regular Colgate, but Colgate Total.

2. Soft bristle toothbrushes are better than the stiffer ones.

You're welcome.

Georgetown Week 8

2009-07-02T18:16:00.000-07:00

I spent Wednesday in the ALS clinic. This was my first real clinic experience, so it was a nice break from the usual inpatient units. It was very much a team approach, comprised of MDs - Neuro and Pulmonary, a respiratory therapist, dietitian (who they just brought one a few months ago), PT, SLP, and an equipment vendor rep who sets pts up with communication devices - because some people lose function of their hands, wheelchairs, etc.

ALS is also known as Lou Gehrig's Disease. It is a neurodegenerative disease and basically pts gradually lose control of voluntary muscle movement, which leads to respiratory distress and dysphagia. Life expectancy is about 5 years. A lot of these pts have PEGs because most of them eventually lose the ability to swallow.

For 2 of the pts, they were losing wt because of increased needs and decreased intake- either they are tired or had difficulty swallowing. So we provided them with tips of how to sneak in extra calories, and lists of nutrient-dense foods. They both seemed to like the idea of shakes/smoothies.

Another pt I saw made me sad. She couldn't use her hands nor could she speak, so she basically couldn't communicate with us, except blink, nod slightly, and smile. But, I heard shes getting a vision communicator that can read her eyes, COOL! Her sister was there with her, and she somehow seemed to know what the pt was trying to say - it was very sweet. The father was also there, and he took us aside and told us that the pt didn't want to go to a nursing home and she didn't want a PEG, she wanted to die naturally. But they were having a difficult time taking care of her at home because they themselves are old and the pt can no longer walk, so they have to carry her!

We ended up talking to her about a PEG. The pt wanted to know (per her sister) exactly what it is, how it works, if she can shower, still eat, taste any food, etc. So we gave a thorough explanation and said its good to have incase she's too tired to eat sometimes, and so that she doesn't have to worry about getting enough nutrition. Afterwards, the pt seemed more open to the idea of a PEG.

Just a note..it is important to discuss getting a PEG with these pts right away because as the disease progresses there is also a progressive loss of function in respiratory muscles. In the later stages, impaired respiratory status makes these pts not good candidates for PEG placement, and other nutrition options may be needed, depending on code status.