Final Post... Or Is It?

Wow, I really got sidetracked from blogging during the last few weeks of the internship, and then again after it ended because I was studying for the RD exam -- which I PASSED, thank you -- and now I'm in the process of trying to find gainful employment.

I'm sorry that I don't have the motivation at this point to go back and reflect on the whole process. I'm both glad and sad that it's over. The intern class had a tearful appreciation ceremony for our incredible director, Debra, and I will miss her and having the other interns in my proximity, though I plan to keep in touch with all of them. Two of the interns are already employed and at least one of them, sadly, is moving away from Seattle for her new job.

So, wow, it's over. I say "wow" again because wow, it's really over! It was relentlessly challenging and an incredible growing experience. Not just the internship, but the process of learning to be a student again, getting through the science prereqs, meeting the challenges of the Masters program, the gut-wrenching internship application and matching process, and then, finally, the internship. Actually, the final hurdle was the test. And here I am. An RD. Woohoo!

Up Next... Staff Relief

Note written by the hospital chaplain in a patient’s chart: “Lively lady… everything is okay with her soul.” That’s all it said, but I guess that’s all it needed to say. I thought it was kind of sweet so I wrote it down.

I had one day of staff relief on Friday, since Monday is a holiday. It wasn’t much different from what I’ve been doing up until now. I’ve had my own list of patients now for a couple of weeks and a good amount of independence with someone to help me or back me up when I needed it. It’s funny… at the beginning of this internship, staff relief seemed like the most stressful thing I would do in the internship. I was terrified that I wouldn’t be adequately prepared by now to help with a patient’s medical care.

Now that I’m here, I realize I’ve already made it through the hardest parts – the changes in schedule every couple of weeks, constantly meeting new people who are potential future employers or coworkers, the changing demands at each rotation, the public speaking (good God, there was a lot of that!), the constant trickle of projects to complete and deadlines to meet. I’m not saying I’m not being challenged by staff relief, but it’s a challenge I do feel adequately prepared for, and I’m glad that it came at the end of my internship instead of earlier, as I know it did for some other internships.

Following staff relief, I have one week of wrap-up with my intern class, including presenting our case studies to each other, taking an exit exam, and getting our evaluations, and then we’re done! After that, it’s a matter of waiting to hear that I can sit for the exam, taking the exam, and then I’ll really and truly be an RD. Can’t wait!

Clinical Weeks 4 and 5

So I’m not going to write about doctors who overfeed their patients after all. Those of you going on to an internship will learn about that soon enough. Instead, here are some little snippets from the past two weeks.

The leash has been let out a little, and I’m assessing and treating patients with little correction from my preceptor – I’m sure to ask lots of questions before I write that note, though! I’m seeing between 6 and 8 patients a day, with the chart review taking me at least 2 hours before I even make it to the floor. It’s very satisfying to see a patient moving towards wellness, though the structure here doesn’t allow one RD to follow the same patient very easily, so if I want to follow a patient I have to do it in my spare time. The nurses are starting to recognize me.

I have a favorite doctor here who likes to teach during rounds. He acknowledges all the members of the team and values input from the RDs. He’s not the only one of the doctors to do this, but he seems more passionate than the others. He’s even a little spiritual.

The protein recommendations I made on my case study patient (I mentioned this in my last post) finally made it into the patient’s care plan when another doctor noticed the need for extra protein for the stage III decubitus ulcer on the patient’s back. Nice to have the attending physician back me up. Also nice that I have personally made a difference in that patient’s care.

I had one bad day last week when I couldn’t get a handle on my patient load and felt scattered and off-balance but then I realized that I was trying to keep pace with my preceptor, who’s been doing this for 20+ years. That’s definitely an effective way to sabotage one’s confidence. The next day I came back and did things at my own pace and still got everything done… and did it much better. Lesson learned.

So overall, I’m still having a good time. I hate to admit this as a Bastyr-trained nutritionist, but I’m not so horrified anymore by the idea of tube feeding and parenteral nutrition. No, it’s not whole foods and home cooking, but it can save people’s lives. I can add that this hospital is doing a great job with the “hospital food.” They buy some organic foods, they don’t like hormones in their dairy products, and generally they make tasty, nourishing meals. And the patients love the food (for the most part anyway… you can’t make everyone happy all the time).

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.