Clinical Weeks 2 and 3

Syndrome of inappropriate antidiuretic hormone hypersecretion (SIADH), rhabdomyolysis, superior mesenteric artery syndrome (SMA), esophagogastroduodenoscopy, and anastomosis … just a few of the intimidating terms and word combos I’ve encountered this week. I won’t bore you with the definitions, especially as that would take away the pleasure of looking them up yourselves, or encountering them in your own internships.

These past two weeks have not been vastly different from the first week in terms of interesting and tragic cases. Newly-diagnosed AIDS, brain death from an asthma attack, and the surprisingly frequent hushed declaration during rounds in ICU that "support is being withdrawn" have indeed kept me in a heightened awareness of the friability of life.

And, yes, the victories are there but they seem to be quieter events because they are gradual returns to some level of stability or an improved functional capacity rather than a sudden, dramatic occurrence. The discharge from the hospital is a release, where an admission is a call to action for medical practitioners. What's more, the RDs are not usually involved in the discharge and often only find that their patient has gone home when they disappear from the census.

What is different this past week is that my ability to understand medical information from outside the realm of nutrition is growing so that I can see my role in the patient’s care as part of the medical team. And the synapses are finally forming between the sections of my brain where information about biochemistry and anatomy and micronutrients and physiology were stored during school. It really is all coming together, just like they said it would. I guess "they" know what they're talking about after all.

I had a really great moment this week when a note I’d written suggesting changes to a patient’s TPN order based on the "2009 ASPEN guidelines for the critically-ill obese patient" got a “Thanks” from the doctor written at the bottom of the note. I had to ask one of the RDs, “But what does this mean?” There ensued an exciting 24 hours in which I checked the chart two or three times looking for a new TPN order based on my astute recommendations but, apparently, the “thanks” was just an acknowledgement because a new order never appeared. Still, the dietitians urged me to make a copy for myself of this rare recognition from an MD, especially from a surgeon, and everyone in the office had to read the note to try to discern its specialness. I was exhilarated by the response but saddened that this was such an extraordinary event that it got the whole office in a lather. The same doctor later (coincidentally? probably...) requested a nutrition consult in a medical situation in which he'd never asked for the RDs help before.

On a lighter note, what is it about the nutrition office that attracts chocolate, cake and candy? This week there were five separate deliveries of goodies from coworkers and industry reps. People “stop by” when they’re looking to satisfy their sweet tooth. In an ironic Pavlovian twist, someone from another department told us that when she sees us in the hallways, she thinks of chocolate. I suppose it's not so bad for people to think of something sweet when they see a dietitian, but when I think of dietitians I think of fruits and vegetables.

Come back next week to hear all about how doctors love to overfeed their patients in the hospital...

Clinical Week I, continued

This weekend I had time to reflect on the amazing range of patients I’ve seen in the last week, from relatively healthy and alert people who were recovering well from hip or knee replacement surgeries, to brain-dead or severely ill patients whose families were having to face the difficult reality of letting their loved one go. Spanning this medical continuum was a patient who had come in for an elective surgery and ended up cascading through progressively more severe complications (respiratory failure, acute renal failure, sepsis) until the original diagnosis seemed as mild as a head cold. A hospital is truly a theatre of human drama.

On my first day, during morning rounds we stood outside a patient's room as the doctor announced that the patient was being taken off of life support that day – behind us in the room the family had gathered to say goodbye. Strangely, they broke out in a bout of laughter as we stood there. I wondered if they were sharing a funny story about the patient.

Shortly after that, the doctor had to run off to replace a trach tube after a patient (coming out of anesthesia and probably confused) pulled it out. The next day, I shadowed a diet tech as she interviewed a patient with rapidly worsening encephalopathy who was almost incapable of motor control, or coherent speech... the patient’s spouse was haggard and seemed close to tears, but maintained control long enough to give us the patient’s food allergies and preferences. Later that day, a rapid response code was called when the same patient became violent with a therapist.

Today, I was reviewing a chart in the ICU as weeping family members walked the halls together, having just lost their grandmother/mother/wife/sister. While I relish a good cry over a tragic story in a book or movie, here “in the flesh” it is too close to home. In these patients and their families I see myself, my husband, my mother, my brother and his family.

The staff here are respectful and never callous about these situations, but seem able to shrug them off, allowing the drama to go on in the background like a television with the sound turned down. I haven't yet learned this skill and am distracted and unable to pay attention to the RD as she tells me where to find the patient's weight in the chart.

I can’t imagine what the next nine weeks will bring but I hope to witness some victories in addition to the tragedies (sooner rather than later, please), and promise to continue to recognize and acknowledge the drama as it plays out around me.

Clinical Week I

First week of clinical – two days of orientation to procedures and protocols, charting methods, and the numerous floors and care units throughout the hospital, including NICU (neonatal intensive care unit), ICU and ortho.

The dietitians’ office is small and swarming with RDs and diet techs, but it’s cozy and the respect and camaraderie between everyone is apparent. Most of the RDs have been here for more than 20 years. It’s hard to believe that in a mere two months I will be competent enough to be in charge of my own floor for two weeks…

Observations on Institutional Food

I’m long overdue for a new entry -- since my last post I’ve been at WIC, at a local advocacy organization for people with gluten intolerance diseases, a school district where the school lunch revolution has already been underway for a while, and I spent a week with a university professor learning about what it takes to teach at the college level. Lots of great experiences that I will not unfortunately have time to recount here. I do have something to say about my last rotation, though…

I spent a few weeks in a long-term care facility doing both food service and clinical work. Long-term care is something I’ve thought about as a career because it seems to be a field that requires a balance between clinical knowledge and people skills, and there is an opportunity to develop relationships with patients, unlike hospital dietetics.

This rotation gave me three different perspectives on food service production in a large facility. I learned how to turn out large amounts of food efficiently and cheaply as part of the kitchen staff. I learned how to develop a week’s menu in the role of the dietitian, trying to achieve the mean feat of balancing nutrition, flavor and appearance while giving the people what they want (by “people” I don’t just mean the residents – there were money-crunchers to satisfy as well). Lastly, I saw the food as the residents saw it and tasted what they tasted.

There were some good things: alternatives to the main menu were available, like veggie burgers, non-dairy milks and gluten-free products, and fresh fruit and green salad were always offered. Some dishes were made from scratch. Most dishes came out of a can or box with a list of ingredients that defied even the most literate reader, vegetables were often overcooked, and the meat was so dry and tough that an able-bodied young person would have a hard time slicing and chewing it, let alone an arthritic, palsied, or dentured senior. Most striking was the contrast of oversalted processed foods with the completely unseasoned vegetables (in compliance with the facility’s no-added salt dietary protocol which, oddly, doesn't prohibit the facility from purchasing high-sodium processed foods).

I was surprised, though I shouldn’t have been, to find out that for the most part this is what the seniors were asking for. When this particular facility offered homemade soup, the residents wanted their Campbell’s brand soup back! Remember, the current population in nursing homes is made up of the generation that saw the advent of convenience foods. Packaged foods and TV dinners were a revelation to them (and I loved them as a child, too). It’s no wonder that these seniors in their convalescence are craving the nostalgic flavors and textures of Krusteaz pancakes, Jell-O, and Campbell’s tomato soup.

I was also surprised to have a conference with a 60-something resident of the facility (one of the younger generation there) towards the end of the rotation who was asking for more beans on the menu, more whole grains, more choices with the salad, a wider variety of foods, more dishes made from scratch. When she heard I was from Bastyr, her eyes widened and she pointed at me and said, “Then you know…!”

In defense of the dietitian who plans the menu there, I explained to the resident that there were conflicting desires from the different generations at the facility, and budget requirements that made it hard to get past the processed food mentality, but I also told her that I thought change was a-comin’ because of her generation. I encouraged her to keep asking for what she wanted, and told her that I thought it would soon behoove facilities like this one to proactively plan for incoming residents who are more sophisticated (purely because of greater access to information) about nutrition, whole foods and healthy food choices.

Earlier in my internship, I accompanied a dietitian who is an expert on gluten intolerance diseases on a consult with a different long-term care facility. This facility had a prospective resident asking about their ability to accommodate a gluten-intolerant individual and they were inquiring about how to get gluten-free certification for their kitchens. That was a revelation to me, that a single inquiry could prompt such a change, but clearly these are businesses that will have to work to gain an edge in the burgeoning assisted living market.

What a great opportunity for nationwide food reform! If these incoming generations of seniors manage to bring about enough change in assisted living facilities, a nursing home might look good by the time I’m ready for one.