Tag Archives: clinical

The Interdisciplinary Team: How an RD Fits

One of the things that drew me to become a Registered Dietitian was working directly with other people and helping patients live healthier lives.  Clinical nutrition wasn’t my dream career while I was still in college; I always thought clinical dietitians worked independently on their patients, who they only saw for a few minutes for assessment anyways.

After completing my clinical rotation, however, I quickly saw that I could still enjoy face-to-face contact with not only my patients, but also my co-workers.  I loved being part of the interdisciplinary medical team, going on rounds and discussing the patients’ plan of care.  It feels really good to contribute to someone’s recovery, especially in such a specialized field as nutrition.

Here are a few members of the medical team that I work with on a daily basis:

Nurses & CNAs: These individuals are my number one allies.  They are the ones that spend the most time with the patient.  They can see how well the patient is eating, if they have GI issues, or if they have wounds that require extra nutrition to heal.  They are also the ones administering tube feeds and checking residuals.  Additionally, they are much easier to get in touch with than the doctors, and can be a valuable advocate for my recommendations when the doctor does come around!  Every time I respond to a consult, finish an education, or drop off tube feed orders, I let the nurse of that patient know.  He or she starts to recognize and trust me.  In fact, I seem to get more consults and calls now that I have established professional relationships with the nurses on my floors, which is great!  (Plus it’s always nice to have people smiling and saying hello to you, instead of “who are you?”)  The only thing I’ve had to really push for them is at what residual level you need to stop a tube feed (ie please do not stop a 65 ml/hr tube feed when you get a residual of 40 ml! Check the nursing manual! This person needs their calories & protein to heal!) However I have the utmost respect for nurses and everything they do.  My own mother was a nurse!

Speech: Speech Language Pathologists aka Speech Therapists do not always teach people how to speak; they assess everything in the vicinity of the throat.  They are a dietitian’s best friend when it comes to determining patients’ ability to swallow.  This is mainly for older adults, those with a stroke, or certain other medical issues.  Sometimes I have to delay my nutritional assessment until Speech comes through with their recommendations; I can’t recommend extra protein or a particular diet order if the patient can’t even swallow! (And in that case, they’d probably need a tube feed.)  Also, they are the ones that recommend modified textured diets; for example, it is easier for people to swallow pureed foods and thickened liquids than dry foods and watery liquids.

PT/OT: Physical and Occupational Therapists are vital for anyone needing any sort of rehabilitation after an operation, trauma, stroke, etc.  Learning from PT that my patient on a continuous tube feed is ambulating in the hallways and doing exercise regularly tells me perhaps I should switch them to bolus feeds.  Learning from OT that my stroke patient can feed themselves with utensils tells me to monitor their meal intake closely now that they are eating without assistance.

Social Workers & Case Managers: When a patient cannot afford the food they need to keep them healthy after discharge, social workers can recommend food assistance programs, community meals, and other resources.  They can also coordinate home care, nursing home referrals, home tube feeds/TPN care, transportation for follow-up appointments, etc.  I’ve had to work with these individuals on several occasions to make sure the patients have a smooth transfer out of the facility in regards to supplements, education, and tube feed orders.

Doctors: In my experiences, the doctor has always needed to sign off my orders, so they have the ultimate say in what happens.  For the most part, they take the dietitian into consideration.  I especially enjoyed clinical rotations in teaching hospitals – students and interns were quick to listen and go with what the dietitian had to say.  On the other hand, some doctors are less receptive to the input of a dietitian, which any RD will tell you.   Also some doctors have crazy schedules that have them visit patients at 6 am or 8 pm, making them hard to get a hold of.

Throughout my internship and beyond, I’ve had to push my way through in a few patients – namely ones on total parenteral nutrition (TPN, which is basically a nutrition IV) – to give them optimal nutritional status (ie- if the gut works, use it!)*  What the doctor says goes, but I’ve had a few instances where I had to be pretty convincing in my charting, as well as verbally defend my recommendations.

*Going with this example, some people (nurses, patients/families, and doctors alike) think TPN is an easy fix if someone cannot eat by mouth.  However, it can be detrimental to use TPN if the person has sepsis (you’re pumping sugar straight into infected blood, feeding the bacteria!) or diabetes (you’re pumping sugar straight into diabetic blood, making it difficult to control blood sugars!).  Also the intestines actually function as part of the immune system, so by eliminating use of the gut, you may be decreasing their immunity.  Not to mention potential overgrowth of intestinal bacteria, sky-high healthcare costs associated with TPN, risks associated with placing a central line, etc.  Ok, enough with my TPN rant….

What I’m getting at is this: RDs are the nutrition experts, and we are a valuable asset to the medical team.  Working with these other professionals is extremely rewarding, and you can learn so much from everyone else.  At times you have to stand up for yourself, but you also have to step back and see the big picture.  Nutrition may not be as important as say, SURGERY.  Nutrition alone CANNOT FIX EVERYTHING.  And very importantly: you can’t make it personal if a doctor decides to ignore your advice.  That’s when the issue becomes about YOU and not the interest of the PATIENT.

The medical team, not to mention the patients, rely on us to convey cutting-edge, research-based nutritional interventions.  Contributing patient care recommendations in the specialized field of nutrition is interesting and rewarding.  It’s so gratifying when you can work together with the other disciplines for the patient’s benefit!

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Life is Taking Me WHERE? Learning to Fit In

I grew up as a Coast Guard brat, moving around the country every few years. I ended up spending my entire high school years in Maryland, where I also ended up attending the University of Maryland, College Park as well as my dietetic internship.  Watching my mom deal with all the moves when I was growing up made me decide that I would never want to marry into the military life, and I loved Maryland.

Fast forward: in college I met an Army ROTC cadet who I ended up marrying during my internship in 2011.  (Guess you can’t really help who you fall in love with, right? And turns out he’s worth it to deal with the whole Army thing 🙂 )  And now, here I am, an Army wife who last summer had to relocate to a strange new place, leave all my friends and family behind, adjust to married life, and…oh yeah, pass the RD exam and start my career

El Paso Juarez Exit

Careful you don't take a wrong turn and end up in Juarez by accident!

Last summer I moved to El Paso, TX, which is a sprawling city (pop ~650,000) in west Texas that immediately borders Juarez, Mexico.  Before you jump to conclusions about what it’s like to border one of the most dangerous, “murder capitals” of the world, El Paso has recently been named one of the safest cities of over 500,000 people, which I can agree with.  Plus our neighbor has some WONDERFUL influences on us, not to be forgotten – Juarez contributes a lot of beautiful art, delicious cuisine, and citizens from both sides of the border are the friendliest population group I have ever been among.  Bordering Mexico does have challenges, however, such as a HUGE cultural shift from the East Coast, including the language, food, and lifestyle.

**Note: I really enjoy living here! Of course adjusting was difficult but El Paso really is a wonderful place.  I encourage anyone to visit before they judge it!**

I decided early on that finding a job working in clinical nutrition was probably my best bet in this locale:

  1. It would be a good experience to work in clinical right out of my internship to continue sharpening my skills in assessing, interviewing, educating, and intervening in a variety of patients and conditions.
  2. All the community nutrition jobs (primarily for low-income El Pasoans) required you know Spanish, and for good reason. Hospitals have staff that could help translate – I only know a small amount of conversational Spanish. (¡qué lástima!)
  3. Many organizations such as dialysis centers required at least 1 year of experience outside of the internship.  I had 0.
  4. Working for a national hospital company may benefit me in the long run by allowing me to relocate within their system as I need to move around with my husband.
  5. I like clinical!

My internship provided me with so many rotations in so many different places, and as a result that experience REALLY helped.  As I interviewed for jobs, I had a lot of insight on how various facilities can differ in terms of management style, workplace culture, RD job duties, and patient population.

I was thrilled when I found an RD position for a medical center nearby, working alongside a few other dietitians, only one of whom is Hispanic and Spanish-speaking.  Not to say it hasn’t had its challenges!

I’d say about half of my patients do not speak ANY English.  Some of them don’t even live in El Paso – they came from across the border.  I’ve learned that in my facility, asking nurses to help translate is the best option, if they’re available to help.  Most of the nurses are from around here and are fluent in Spanish.  One time I made the mistake of having a patients grandson help to translate what was supposed to be a brief, simple education, and boy was that a mess.  He didn’t understand what I was trying to say, so the patient ended up even more confused; I ended up having to wait for the nurse to come help anyways!  Plus the nurses are usually familiar with the educational content I provide, so they know exactly what I’m trying to say as well as how to explain it, unlike a family member.

Often times I also ask for assistance from the Spanish-speaking RD on staff, who has been extremely helpful!  She’s also helped teach me about common food items and other cultural differences in El Paso that I’m not used to.

Here’s my main point: My advice to any dietitians (or even nurses, doctors, or other healthcare workers) who must move to an unfamiliar place…immerse yourself in their culture, and find a local to enlighten you on how people live.  Joining the local dietetic association was also really helpful- you’ll meet RDs who have lived there forever.  I realize El Paso is a pretty extreme example, but the same advice applies.

The bottom line is if you don’t know your patient population, you can’t do your job well.  This is especially crucial when you’re dealing with their eating and lifestyle habits – I can’t tell a person of Mexican descent to stop eating tortillas, that would just be loco.  Number one rule of nutrition counseling is to work with the patient to make small changes to gradually lead to big improvements.  I need to know the baseline diet of the average person here in order to meet them on their level.  To do that, I’ve visited the grocery stores (including the Mexican markets), read the local paper for specials and restaurant reviews, explored menus, grilled my coworker who is a born and bred El Pasoan, and even sampled the local delicacy – Chico’s Tacos (the locals love it but I had a hard time stomaching it haha).

Chico's Tacos

El Paso fare - Chico's Tacos

It’s a whole different world than the one I came from, but it turns out I have adjusted pretty well and now I am really enjoying my time here.  Working as an RD in a foreign place is a challenge, but I know it’s making me a better dietitian in the long run!

If you have any tips on adjusting to different cultures in the nutrition or healthcare industry, please share them!

Closing Thoughts on Clinical

Clinical dietitians

Posing with 3 of the amazing RDs I worked with for the majority of clinical!

Let me start out by clearing something up- when I claim “I Survived!” I am not trying to imply that there was doubt of my survival or that it was hard to get through.  On the contrary, actually. It’s just that most past dietetic interns I’ve spoken to have said that clinical is intense and pretty overwhelming at times.  I’m not going to say it wasn’t a little tough at certain points along the way, but that’s how you know you’re getting something out of it.  If it was super easy and a breeze to get through, what good would that do?  Bottom line is to not be afraid of a clinical rotation because you don’t think it’s for you or because you don’t think you’ll be good at it or you’ve heard it’s hard…or whatever.  Because I thought all of those things and look at me now- I loved it and wish I could have stayed longer!

I Survived!

Last day in clinical

Goofing off with another intern on my last day!

And clinical turned out to be a truly wonderful experience that I will miss very much! In addition to working with great dietitians, I got to spend a lot of time with another intern from a distance program.  So it’s been 12 weeks into my dietetic internship…and the “hardest” (or so I’ve heard?) rotation is out of the way.

Next week we have two class days and then are off for Thanksgiving. The week after, I will be working with the Food Supplement Nutrition Education program (FSNE), which is part of Maryland Cooperative Extension.

Critically Progressive

It is my last week in clinical!  I cannot believe it.  Next week we have two class days and are off for 3 days for Thanksgiving.  Then I will start my other various dietetic internship rotations, which are in MUCH quicker succession.  Hopefully my blog will get a lot more interesting 🙂

Calculator for tube feeds

Glued to my calculator figuring out tube feeding orders.

Staff relief has been wonderful.  It’s been my favorite part of the internship so far- I’m basically a dietitian at the hospital.  The independence is great!  Last week I was mostly covering the critical care unit as well as a few med/surg patients.  I ended up doing so many tube feedings that I’ve become really comfortable with ordering them.  This week, however, my preceptor has put me on a different floor; I saw oncology and progressive care patients (with many different diagnoses).  The variety is refreshing…as well as the ability to actually speak to my patients, which is my favorite part!

Photo Evidence!

For the UMD College Park dietetic internship, we are encouraged to take photos on our various rotations and use them on the internship blog, facebook, and our websites that we are making.  Well, I finally got around to uploading some pictures from my camera and I remembered that I took a photo from when I was at the VA.  Here is a picture of me with a few of the dietitians I had the pleasure of working with! (I am second to the left)VA Dietitians

Staff “Relief”?

It’s down to the final two weeks of my dietetic internship clinical rotation: staff relief.  This is when I return to my original hospital that I spent 8 weeks at to perform as a fully-functioning dietitian.  After spending two amazing weeks at the VA, returning to my old hospital and trying to get back into how they do things was a little stressful at first.  For example, at the VA dietitians recommended tube feeding orders that the doctors could order, by describing it in notes that they submitted to the chart.  At the hospital I am at now, the dietitians actually put in the order themselves.  Since it is computerized, it took me a while to remember all the various steps of submitting the tube feeding formula, initiation, rate, additional instructions, attaching physicians, and electronically signing.  Luckily I picked it Continue reading