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Monthly Archives: October 2010
Wow, so it has been a while since I last updated about my dietetic internship. I have a good reason though! My preceptor put me on staff relief last week. This is earlier than normal and I am honored that they entrusted me with those duties! Not to mention it was the critical care unit! Needless to say it was quite busy between going on rounds, visiting patients, writing tube feedings, and working on my clinical homework and major case study. The ICU is no joke and I have to say it was a bit stressful at times (mainly the first day I was doing staff relief and I felt a tad overwhelmed) but I quickly adapted to the responsibilities and even spoke up during rounds, where the nurses and doctors go from room to room and discuss each patient. I don’t think they really knew who I was, just some random person in a lab coat following them around, until I piped up about a certain patient’s tube feeding being changed that day. They were all sort of shocked (and appreciative) and it made me feel really good to contribute!
This week, I am finally switching it up and changing hospitals for a couple weeks. Yes, I am still in the clinical rotation in my dietetic internship, but I am going to a different place to see a different perspective. I will let you know which hospital it is once they give me the OK to post it in social media. I am excited and a little nervous- I have grown so used to the hospital where I have spent the past 8 weeks. However, I will return to my original hospital in 2 weeks to do 2 weeks of full-on staff relief. Until then, this new hospital will give me another view of how a hospital can be run, because to an extent each hospital can be pretty different. I will definitely update by the end of the week to update on how it’s going there!
This week has been very busy. My focus has shifted more to critically ill patients and those needing enteral feedings, which are formula feedings through the nose or through a tube connecting to the stomach/small intestine. I’ve had to pick out which formula to use, their daily needs for calories and protein, and how much they need to be given per hour. Its using a few algebra skills as well as clinical judgement.
One lady I wrote an order for has a jejunostomy tube, which is a tube that connects from the skin to the jejunum, a part of the small bowel. She is on enteral feedings at home, and uses a particular formula that is pumped into her during the night. However, she is post-op from surgery, which automatically increases her nutrition needs- mainly protein! Extra protein will help her body to heal better. I went in to speak to her about starting her tube feeding and she was worried about switching formula; sometimes with different formula compositions, some side effects such as diarrhea could occur. I assured her that we would be following her very closely to make sure she was tolerating it ok, and that her body needed the high-protein formula. She and her husband were glad I took the time to speak to them, and I was too!
A lot of the other enteral feedings I ordered were for people who were unable to speak to me- and visiting with patients is one of my favorite parts of dietetics- so I was glad to have this interaction.
Having the ability to order tube feedings is pretty awesome, if I do say so myself. It’s nice to have a definite impact on a patient’s plan of care. With interviews and recommendations, you never know if the patient is really going to be impacted by what you say or if the doctors are actually going to listen to you. Tube feedings are another story- once the doctor gives the word, it’s all up to me!
So although it’s been hard having more serious cases on my hand, I also had some more good interactions with patients last week. Take one patient who all of a sudden had kidney failure. Kidneys are responsible for regulating electrolytes (levels of sodium, phosphorus, potassium, etc in the body) and fluid (retaining/excreting water/urine). This person had no history of kidney problems, until his primary care provider did a routine blood test that showed abnormal kidney functioning. Sent to the ER, the patient was told that they had to go on dialysis! They also found that he had high levels of potassium in his body, a condition called hyperkalemia, because he was unable to get rid of enough of it due to his impaired kidneys. Too much potassium could potentially cause heart failure, so it’s pretty serious. I went to go talk to him about a “renal diet”, which is low in those electrolytes I mentioned previously. I even gave them a list of foods high in potassium that he should try to limit. The poor wife was shocked when she realized she had been feeding him potatoes, lunchmeat, soymilk, and spinach, which are all high sources of this micronutrient.
I had just printed out the list of high potassium foods when a doctor happened to need to get on the computer next to mine. He saw the list of foods and he said, “I had no idea all those foods had so much potassium in them! Usually I only tell them about bananas” (which are a more commonly known source). That’s when the other dietetic intern piped up “that’s why you should consult a DIETITIAN.” And it’s true. Doctors know so much about so many things, but nutrition is such an intricate, involved part of the medical field that is often overlooked and undertaught at medical schools. Which is why we have dietitians, who are health professionals that devote themselves to this specific part of medical knowledge. It felt good to make that impression on a doctor, even as just a measly intern, that we ARE an essential part to a patients plan of care!
Back to the little element that started it all: To find out more foods high in potassium, check out this list from the USDA. If you have normal kidney functioning, you don’t have to worry too much about it- potassium is important for a healthy body! It’s even supplemented to some people suffering from hypertension.
I, for one, have never had to stay in the hospital more than maybe a night in the emergency room. No one close to me has had to be hospitalized for a lengthy amount of time that I have been old enough to remember. (Both things i am extremely grateful for!) Therefore, working at the hospital does give me a big dose of reality- that there are REALLY sick people out there. People who led healthy lives that suddenly are dying of cancer. People who will end up with diabetes and renal failure. Others with devastating strokes.
Today I spent some time on patients in the Critical Care Unit, the ICU if you will. That’s where the sickest of the sick end up. I had to recommend tube feedings to two patients. One of the patients was probably going to end up in a long term care facility, never being the same after a terrible cerebrovascular event. The other was being considered for hospice, which of course means that he is getting ready to die. Today I left with a different perspective. Instead of happily bopping into patients rooms and teaching them how to order off the menu, recommending supplement shakes, or teaching about nutrition with whatever new disease they acquired, I had to sit at the computer and think about the severity of their conditions. It didn’t help to run into a family that was crying for another patient further down in the ICU.
It kind of makes you appreciate life, you know?
My mom, a former ICU nurse, made a comment a week or two ago about how patients love students in the hospital. Probably because we’re not used to being in this environment, we almost care too much! One of my patients dying or being close to dying affects me quite a bit. I know in time it will impact me in a lesser way, but it’s definitely something that takes getting used to.
I don’t mean to complain; I know doctors deal with this stuff all the time. But it’s almost reinforcing my original plan to get into public health- prevention!
I still can’t believe it’s October. Where has the time gone? I’ve been seeing tons of patients at the hospital. As my sister puts it, “saving the world” except, not. Just trying to optimize people’s dietary intake is all. I’ve seen a lot of cancer patients who need supplemental shakes to boost their caloric/protein intake, and many cardiac patients who need to cut back on their caloric/fat intake. Even when the doctors ignore my recommendations, I know that I’m still making an impact when I am able to spend time with the patients and really work with them. There’s also been a couple quite remarkable cases that I feel I would be violating patient confidentiality if I posted about, but let’s just say it’s been pretty interesting!
Monday was a class day where we learned about FSNE, or Maryland’s Food Supplement Nutrition Education program, commonly referred to as Food Stamp education. We will be doing an in-depth research project for them evaluating their educational curriculums for people who are receiving food supplement aid. We also were able to learn about tips on general nutrition education practices. Food stamps reach a lot of different populations, so you never can predict how a class will go. Several nutrition educators for FSNE were in attendance, so they were able to offer ideas on how to cope with various situations.
Anyway, tomorrow I will be going to the hospital really early to hear a recognized expert on diabetes talk about diabetes and heart disease. It should be interesting to hear about, since so many of my patients have both of those conditions! For now, I must work on my Critical Care homework set. I’ll try to update again later this week!