pickled pigs feet!

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!

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!

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

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.

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

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

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

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

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

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!

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!

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!

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

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

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!

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

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

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

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!!

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....

...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

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...

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

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

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

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

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?

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

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

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

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!

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

...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

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

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

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

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

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

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

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

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.

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

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

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

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

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

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

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

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

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:

1. 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).
2. 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.

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

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...

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

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

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?

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....

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

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

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

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!

( 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

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.