Big Fayetteville. Week 2.

This week has been a bit of a change from last week. I've been working at a smaller hospital called Highsmith that is an offshoot of Cape Fear, and only one RD is employed there, so we've been having some quality time. I've been writing a bunch of notes (not in NCP format...), and I even got to formulate a TPN recommendation (the RD can't order a TPN, frustrating...). Sometimes I feel like I'm just typing on the computer all day and not really getting to see any patients. And sometimes I feel like I'm making the same recommendations over and over again to no avail. But I have gotten to learn and witness interesting things. And I have gained an appreciation for people who work in hospitals and deal with tough situations constantly. Today, a PT named Laurie (we're buddies) let me come watch her change the dressings for several stage 4 ulcers. The patient was a 19yo guy who was quadriplegic from a gunshot wound. I just cannot imagine being that young and being confined to a bed for the rest of my life. But that is what we are here for. To help these people. What beautiful lives of service we have ahead of us, no matter which career path we choose.

And I also got to be a part of a sleep apnea support group (which included about 50 people) this evening. The RD that I've been working with, Erin, gave a talk about weight management, and asked if anyone had any nutrition questions. We just got bombarded with random questions about Splenda, chemicals in foods, gluten allergies, green tea, the ol' butter vs. margarine debate, etc, etc, etc. It was a helpful learning experience for all involved.

And P.S. If you are ever considering joining a gym that is a bit far away and is kind of junky but offers a fairly cheap student discount which is really not all that cheap if you are on a budget, just wait a day before you cement your decision. Because you will probably end up meeting some guy the next day who will give you a 2 month free pass to a super nice gym right next to your AHEC that you thought was too expensive to join which was why you chose the cheap gym far away from your house in the first place. Lesson learned.

First day on the floor

So yesterday, I attended the hospital's orientation. Today, after being outfitted with a badge and a beeper (!), I was finally allowed to go up on the floors and shadow my 1st dietitian. We spent most of the day in the Rehab center here, where we saw a wide variety of cases and conditions. I got to see two patient educations: one on a fluid restriction/K+ restriction and one on a carbohydrate consistent diet (that's what a diabetic diet is called here). We also saw a Marine who ended up on Rehab with some pretty serious injuries after falling off a third-story balcony while drunk. Working in a hospital and hearing the horror stories can really make you value your safety and make you want to take good care of yourself.

I also learned that even though there is a pretty good system set up to determine who the dietitians will see each day, that system kind of falls by the wayside over the course of the day as nurses and other staff members pull the dietitians aside to ask them to do consults or assessments of other patients on the floor. So being flexible is pretty important.

I also learned how to determine the IBW for someone who is shorter than 60 inches tall (for some reason it had never even crossed my mind that I didn't know how to do that): subtract 2.5-3 lbs. (from 100) for each inch below 60.

Finally, I attended a meeting of the Carolina Coastal Dietetic Association this evening. The snacks included mini candy bars, bagels, and a chocolate chip cookie cake. Heaven.

2nd week in Shelby

So this week has been much more interesting than last week.  The dietitian I have been working with has been giving me a few patients every day to work with.  Several have had ESRD, COPD, and DM.  I was able to go talk to a few patients as well to ask about their preferences.  I have also been helping in the diet office with nutrition screens and becoming familiar with all of the different diets and also how the entire nutrition services "system" works at CRMC.  

This morning I was lucky enough to see a barium swallow.  The speech therapist and a radiologist performed the test which I was not very familiar with.  The speech pathologist at CRMC helps to determine the thickness of the liquids that patients are able to have, and dietitians are responsible for referring patients to speech.  It was good to see to more fully understand how speech and nutrition work together and also how appropriate thickness of liquids can be determined using this procedure.  Hope everyone else is enjoying the second week!

CMC Week 2

Hi everyone,

I've really enjoyed keeping up with your blogs! I'm mostly in General Medicine this week, but something that I have learned is that the dietitians here all really do everything- so while my weeks are divided into rotations, they do a ton of cross-coverage. The dietitian that I am with this week sees a lot of patients with random problems (I saw a lady today with a crazy spider bite, a patient with what they have now identified as liver cancer, a pre-heart transplant patient, and the list goes on). It keeps it interesting. The dietitians also write all of the TPN orders so that is a rush to get those in to the pharmacy in the morning. I haven't written any myself yet, but today I helped look at labs and watched the dietitian make a few changes to a few TPN orders based on the individual's labs.

A few things that I wanted to share-

-I went to "Grand Rounds" this morning with the transplant dietitian, the other intern (in her internship at Winthrop who will be here for the first part of my summer), and the Clinical Nutrition Manager. Grand Rounds, from what I gathered, are for mostly residents and doctors interested in the topic, but they went and invited us because the topic was Liver disease, and the MD speaking was from UNC school of medicine! He had a little test for fun to help the MD's start thinking about liver diseases, and the first one was "23 yo woman with history of hemolytic anemia at age 16 and you see Kayser-Fleischer rings." Thanks to Dr. Beck, I knew that was Wilson's disease...620 pays off already!

-In looking at PN, something that I learned for adjusting K was that for every 10 mEq of K that you add to the order, it should increase lab by about 0.1. So that's helpful if any of you will be manipulating PN orders.

-I got a handout from my preceptor because they use PES statements here, so this handout was concerning if there is no nutrition problem what do you do (because every patient's note starts off with a PES statement, no matter what." I thought this would be helpful for you all in case you come accross this: "Nutritional parameters within normal limits as evidenced by (then include evidence such as BMI, % intake, indicator of visceral protein status, and knowledge of diet)." There's no etiology in there, but I guess you could say something about sufficient appetite, etc. Anyways...just wanted to share that. The note also says that if this is the case, be sure to mention when the unit RD will rescreen in case of nutrition risk arising.

I'm going to watch an open heart surgery on Thursday. I'm excited/a little nervous, so I'll try to report in after that!

Hope you all continue to enjoy your sites!
Elizabeth

SRMC Week 2

Even though I don't have different "rotations" here at SRMC, I have spent most of the end of last week and beginning of this week working with cardiac patients. The dietitian I have been working with works on the cardiac floor, in cardiac rehab and on a general medicine/surgery floor, where a lot of the patients have cardiac issues. Yesterday morning we went over the cardiac rehab center. What I liked most about it was the fact that it is Medicare/Medicaid sponsored, so it wasn't restrictive in terms of who can afford to go. The population in this county is the poorest in the state, so a cardiac rehab program that isn't Medicare/Medicaid eligible would exclude almost all of the residents of this area. The cardiac rehab program is housed in the fitness center that the hospital owns. During normal business hours, some of the exercise equipment is roped off from the general equipment, and there is a nursing and medical staff. The patients have specific appointment times, in two hour blocks, that they come to the center. They first get baseline data taken, like heart rate and blood pressure. For the first two weeks that they are involved in the program, they were a heart monitor throughout their entire workout session. After the first two weeks, they are monitored both before and after their exercise. Each patient who enters the cardiac rehab program is required to meet with the dietitian at least once. For most patients, this is the only time they meet with an RD. Some of them are interested though, and the RD will meet with them as many times as they want, while they are in the program. The patient we saw Monday morning was very interested in changing her diet and we are meeting with her again tomorrow to follow up and provide more information. She had just had a triple bypass, and was beginning her road to recovery. I was impressed by how many changes she had already made, and how willing she was to learn any new changes. The dietitian said she really was the exception in this cardiac rehab program. A lot of the patients are willing to start exercising, but very few want to make any real dietary changes. The food is a huge part of the culture in the area, and making changes makes it harder for them to fit into their own culture. The dietitian tries her best to reach these patients, but has learned that getting them to make one small change, like no longer cooking vegetables in a fat back, is usually the best she can do.

Craven Week 2

Today I ventured for the first time into the kitchen at Craven. First, we went for a department meeting, where one of the dietitians was recognized for 5 years of service. One employee also got recognition for becoming ServSafe certified and another got an award from Sodexo for being a caring employee: during the last ice storm they had he drove out his SUV and picked up everyone for work so they could come in. The food service manager and the clinical nutrition manager seem to have pretty good rapport with the food service workers, as do the dietitians, although the dietitians seem to spend very little time in the kitchen. My second trip to the kitchen was to check up on a gluten free menu for a patient, to make sure they were putting the right things on her tray. They do not get very many celiac patients at Craven and when they do the trays often have inappropriate dietary items on them. I went to talk to the hospitality assistant (kind of like the hostess at UNC, also, Craven is switching to room service next week) and she had marked pasta to go on the patient's tray. I tried to explain that the pasta they used was also made from wheat but she didn't appear to believe me since the list they get says to avoid wheat and she thought that was only bread and gravies. Another employee insisted that pasta was made from corn. But eventually the clinical nutrition manager came in and said pasta was inappropriate and we made up the lady's tray and I took it to her. Unfortunately when I got there I was told the patient was actively dying so her daughter said she would probably be eating the tray. It was sad.

On the clinical dietetics side of things, I've been working beside the dietitians to help with their patient loads. They see upwards of 20 patients a day, it is so fast and busy. I have only seen 3 educations however, and none of them were taken well by the patients, none of them seemed interested at all. I myself have done about 10 breastfeeding educations though, which I have enjoyed and feel very comfortable doing now. I am still nervous about other educations since I haven't gotten the opportunity to do them but I hope as I do more I will become comfortable with them as well. Hope everyone has a great week!

Wake Forest Baptist Medical Center...Day 1

Hello All!
Today officially marked the first day of my internship at WFUBMC! Nothing too unusual. I enjoyed learning the ropes. First I received my badge and a parking pass. Then, I met several of the 26 dietitians at the hospital. (Yes, 26!!) Afterward, I had a private meeting with the medical records manager. She stressed the importance of prompt and thorough documentation. Next, I enjoyed a few hours in the diet office (more food service), a tour of the hospital, and an introduction to the computer system. The day ended a little early after I discussed a few potential projects with the manager and completed a test based on the hospital's diet manual. All went well. Tomorrow I start my General Medicine rotation. I am looking forward to all that is in store. Hopefully it will be a tad bit more exciting once I have some face-to-face contact.

Hope all is well,
Rachael