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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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And the Coolest Place to Intern Right Now is…

Hello all, sorry about another lengthy delay in updates.  My life as an intern has become even more hectic with over 3 hours of commuting to Northern Virginia each day.  Luckily I can often drive in with my dad (who works in DC nearby) or stay with friends who are closer.

But I don’t mean to sound whiny- I feel like the luckiest dietetic intern out there.  Why, you ask?  I have the opportunity to currently be working at the USDA Center for Nutrition Policy and Promotion (CNPP).  Still not clicking?  Well, you may have heard that the Dietary Guidelines for Americans 2010 recently came out.  USDA’s CNPP along with the US Department of Health and Human Services (HHS) are the ones responsible for this project that is released every 5 years.

In a nutshell, I have been afforded the opportunity to be rotating with the organization responsible for releasing the Dietary Guidelines, a document that outlines the best nutrition research out there, DURING the release of the Dietary Guidelines…which only happens once every 5 years.  How cool is that?!

USDA MyPyramid

USDA CNPP is also responsible for the Food Guide Pyramid

The people working at CNPP are so inspiring, whether they are Registered Dietitians or non-dietitians who work to support nutrition communications and policy.  They all seem to love their job and feel very passionate about communicating nutrition to the American public.  Can you tell I love it here, or what?

The projects we are assigned to work on are very exciting!  My partner and I are mainly working with the Nutrition Communication and Marketing Division of CNPP.  I actually can’t share too much with you all because it’s confidential at this point in time…but as certain things are released I will blog about it and let you know what I was a part of.  It feels awesome to know that things I am helping out with now may impact the public on a national level.  It blows my mind!  I mean, I loved helping people on an individual level during clinical, but to reach thousands, potentially millions of people?  I can’t even tell you.  I mean, I’m just an intern!

I’ll return another time to summarize what I’ve learned about the development of the Dietary Guidelines that were recently released.  Looking forward to another three weeks here at CNPP!

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!

Tube-ular!

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!

Validation Through…Potassium!

Potassium
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.

On to the 5th Week

Well, this upcoming week is the 5th week of my clinical rotation.  I have to do 8 weeks at my current hospital, 2 more weeks at a different hospital (just to get another perspective from how another place runs things), and then come back to do 2 weeks of staff relief at my original hospital.  12 weeks total clinical, technically.  It’s a long time, but I don’t mind- I am really enjoying what I’m doing just because it’s so interesting!

Because the 8-week period is halfway over, I had an evaluation  with my preceptor.  He said I’m doing very well so far, which was great to hear!  He even observed me while I educated a patient on dietary interactions with the drug Coumadin.  (Coumadin prevents blood clots by thinning the blood, and you have to watch Vitamin K intake because K promotes blood clotting mechanisms.)  One thing I do need to work on is my “authority”- aka my confidence and portraying myself as an expert (although I don’t feel like one just yet!)  I’m sure that will come as time goes on, however, as I become more and more comfortable.

Friday was an exciting day.  I finished up my mini case study report on a patient I had been following for a few days.  He had not only diabetes…but hypertension…congestive heart failure…and worsening chronic kidney disease!  He was definitely more complex that originally anticipated, but I got to learn a lot about how all these conditions affect each other.  Plus he was the nicest guy who was great to work with.

Friday I also did FOUR patients, which is the most I’ve ever done.  I followed up with my case study, did a diabetes and low-sodium diet education, assessed a patient with severe nausea/vomiting from chemotherapy, and worked with a patient to find soft foods he could eat since he didn’t have a lot of teeth.

This week’s homework topic is enteral and parenteral feeding, which is nutrition support in the form of tube feeding and IV administration.  Speaking of homework…I have to get back to doing it!  I’ll try to update again later this week, hopefully after getting the chance to write some nutrition support orders!