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

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

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

goodbye CMC Union

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

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

Ending on a High Note

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

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

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

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

pickled pigs feet!

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!