SGI

Last week was generally not as eventful as the beginning of the week, hence why I didn't write much. 

This week is GI surgery, which actually encompasses a lot of transplants, bariatric surgery, pancreas issues, and overall GI surgery. There is a separate position for GI medical, so I won't be seeing many issues with irritable bowel, Chron's, or other conditions like those.

Today I didn't see too many crazy patients, mostly just a good introduction. I saw a patient who was post-hysterectomy, and just had to make sure she was tolerating her diet after her surgery and making sure she has adequate protein intake. I also saw a patient who had just had a kidney transplant and...

*drumroll...

I got to practice my first TPN! I was excited to actually practice recommending a specific TPN order on an actual patient. It was good practice and I tried it a new way, which actually made it a lot easier to do. For example...

Estimated kcal needs: 2300 kcal

Estimated protein needs: 100g

If a patient gets two infusions of lipids at 500ml 20% lipids twice per week, that's 2000 kcal (each ml of lipid is 2 kcal). Divide this by 7 days per week, which is an average of 286 kcal per day.

2300-286 = 2014

And, we'd like about 100g protein (in the form of amino acids).

100g x 4kcal/g = 400 kcal

2014 - 400 = 1614 kcal

And, since all we have left is dextrose, we divide 1614 by 3.4 (how many kcal are in one gram of dextrose), and we get 475 g of dextrose! 

So, just to check our math...

475 x 3.4 = 1615

100 x 4 = 400

286 kcal from fat 

Total = 2251

Which, is pretty darn close to 2300 kcal per day! Then, of course, it's important to factor in electrolytes, but that's another different story.

Anywho, that's about the extent of my day today. Apparently there's a winter storm that's "history in the making!" So I'll be staying in Ann Arbor tomorrow night with other interns, just in case :)

...HUHH?

Halfway through the week, and my health is declining. Boo. I've seem to have picked up a sore throat and headache that's not making my week very fun.

Anywho, today I saw a total of 3 patients. One of them had oral cancer and had to have a huge section of their jaw removed, including teeth. I calculated the tube feeding completely on my own - how exciting! And it matched 100% to what my preceptor would have done. Very encouraging. The second patient was just in for chronic pain and decreased weight, but it was more of that she was trying to lose weight and not necessarily unintentional weight loss. 

But my last patient was a hoot. He was an elderly man who was admitted for neck cancer. I went and saw him because his initial patient survey indicated he had some weight loss, mainly from general illness. He was in great spirits and was fun to talk to, and here's why. 

To set the stage, he was hard of hearing. I had to speak very loudly when asking him all the questions, such as when he noticed weight loss, how his appetite was, if he was on any supplements, etc. Towards the end, I could tell he was getting a little tired, so I only had one last question to ask. "On average, how many bowel movements do you have each day?" He gave me a confused look. "How many times do you poop each day?" And still no answer...

"HOW MANY TIMES DO YOU POOP EACH DAY?" 

His response? "Oh! I go to the john about let one go about once a day. No problems there!"

I chuckled as I left the room, and on I went.

Anywho, time for bed. Massive headache pounding. Wonderful.

OTO x2

Today was another day of OTO and SNA. First thing this morning was rounds with the OTO team and then my preceptor and I visited a few patients. Our first patient was a woman with a trach-tube and we had to do a home tube feeding education. At first, my preceptor did the education,  just to show me how it was done and get a feel for what is said and asked.

I really enjoy my preceptor in this rotation. She laid everything out and was clear on expectations, such as keeping notes short and to the point, making patients feel comfortable, and making sure I ask lots of questions. She also asked me what I would like to do as far as talking to patients, such as if I wanted to just go see patients on my own, or have her oversee a patient interview. I chose the latter, and decided to watch her conduct a patient interview, then I had her oversee me, then I went on my own.

I had 3 patients altogether today. One patient was discharged by the time I wanted to go talk to her. Another patient was a cancer cachexia patient and sadly it was an "end-of-life" situation so there wasn't much I could do, but provide them with what they wanted and to make sure they were tolerating everything and were comfortable. My last patient was in for a a head/spine injury, and the craziest thing was that I had to proceed with caution into her room. Not because she had droplet precautions or MRSA, but she was "violent and abusive towards physicians." AKA - she hated everything with a white jacket. So, needless to say, I decided to just call her nurse!

Anywho...153 days...

OTO and SNA

Otolaryngology and neurosurgery this week.

HOW SWEET. The next 3 weeks will actually be exclusively with adults. Which, I'm happy about. Since I'm in the pediatric concentration internship, I was a little weary about what would happen if I couldn't find a pediatric-specific job! But, U of M had it all worked out.

I'll do this week in OTO and neurosurgery, next week in GI-surgery, and the week after in cardiac surgery. All of which I'm very excited about. I only had a half day today, which was fine. It's insanely cold here and it's starting to snow (again). While I had a half day and was technically done at noon, I stayed until 3ish. 

Otolaryngology is basically head and neck cancer. We saw about 3 patients today, plus rounds with the team (RD, doctor, nurses, respiratory therapist, med students, and a pharmacist) so that added another 5-6 patients seen. While there were many diagnoses of these patients, from subarachnoid hemorrage (SAH, basically a "brain bleed") to cancer, to this interesting patient I saw today. He came in with GI bleeding, but he first and foremost had neck cancer. He had the cancer removed, but...he was on a carotid bleedout precautions. Since he just had much of the skin and muscle removed from around his carotid artery in his neck, any sudden or rough movement could make it burst. If it burst...it would only be a few seconds...scary stuff.

A lot of the work in this rotation deals with enteral nutrition, which is going to be great practice. Mayyyyybe some parenteral nutrition.

Overall, it's been a good Monday, I really can't complain. I submitted another journal article, this time this article profiled users of governmental services. So...in 2-3 months or so, I should hear back. Which I'm very excited about! 

And...I got damage done on my literature review. In addition to the endless case studies and full days of seeing patients, interns are matched up with dietitians to complete a literature review. Our (an RD and I) topic is "Determining Energy Needs of Obese Children." Basically, we're reviewing a piece of literature that compares predictive equations for calculating calorie needs. While these calculations work for the majority of individuals, they don't calculate them as accurately for people that are obese.

Think of it this way...if you do the general 25-30kcal/kg for a woman weighing 140lbs, you'd get roughly 1600-1900 calories/day. Completely do-able. If you were to do the same amount of kcal/kg for a woman weighing 350 lbs, you'd get 4000-4800!! Not so logical. So that's what this study was looking at was to compare equations, and even create equations, to better calculate their energy needs.

Free time? What free time!?

I've had a few complaints that I haven't written much this week...oops. It's just been a hectic week, crazzzy cold out, and lots to do. I had to take an unexpected trip home this weekend, so I won't have too much to report...

Next week is adult neurosurgery and otolaryngology. Yes, even though I'm in the pediatric concentration internship, they do give us experience with adults. Which, I'm very happy about. Mainly because there aren't as many pediatric-specific dietitian jobs out there, and if I got a job with adults or just an overall general RD job, it's good to know I have some experience. So the next 3 weeks will be with adults in neuro/oto, GI-surgery, and...something else that I can't think about right now.

Time for bed.

Really?

Yep...almost done with my 3rd week of clinical rotations. CF is an interesting and crazy disease state, and it's weird how the severity ranges from no symptoms at all to a horrible cough 24/7.

But surprisingly, I haven't seen any CF patients outside of the outpatient clinic. We saw about 10 patients in the clinic. If there was no one to see, I was kind of a catch-all for other dietitians, taking patients that would give me good practice. While I am excited to be practicing and getting patients and all that jazz, I'm kind of disappointed in the lack of CF and metabolic disorder patients this week. I mean, it's a good thing that not very many people with these diseases are having such bad issues they have to be hospitalized, but I guess this rotation wasn't what I expected. But don't get me wrong, I've learned a ton. 

I haven't written in a few days because I was somewhat frustrated. Directors told us that each preceptor has their own style and it may, and most likely will, differ from person to person. I am an extremely detail-oriented person and so was my first preceptor. This worked out well and I wrote very detailed nutrition medical documents, without being too wordy or over-the-top. But the preceptor now is the complete opposite. But while going over my notes and it being chopped up, I felt like I was doing everything completely wrong, and it got very frustrating and discouraging. So, when I get back from the hospital, I've been doing some cooking, reading, talking with family/friends/boyfriend, and mostly relaxing.

And, it's almost Friday :)

Onto CF

So I successfully completed my first clinical rotation. WHOA. Definitely learned a lot and I feel like I have a small swing of things. My first rotation was kind of a "catch-all" general rotation, so I saw ketogenic diets, enteral diets, sepsis, surgeries, and all sorts of stuff.

One thing that I didn't get to practice (but I'm sure I will a lot eventually), is calculating a TPN diet. I think this is one of the toughest things I'll have to do and practice, but I feel confident I can get the hang of it. And, it's math, so I'm kind of excited.

But at the end of every rotation, there's an evaluation with my preceptor for that rotation. My first clinical evaluation went well, and I "met" all my compotencies. The choices for the evaluation are "exceeded," "met," "needs improvement," and "did not meet." While all of my evaluation marks were "met," I'm not disappointed in the least bit. It's extremely difficult to get all, or even one "exceeded" for that matter. But, that's not to say I'm not going to strive for it during every rotation. They just want us to know that there is always room for improvement when it comes to clinical duties.

So, this week is a week full of cystic fibrosis (CF) patients. Today was odd and there weren't any patients in the CF clinic, but tomorrow starts with 10 patients to see, another day or two this week, there's going to be up to 12 little kiddos to see! I'm very excited, as I really liked my clinic experience last week. This clinic is actually on-site at the hospital so no driving to unknown places again.

This weekend was amazing and I didn't want to go back, but yet again, if I don't go back, I won't finish...and it looks like I'm about half-way there. Which is insane. But exciting.

161 days...

Clinic? Yep!

It's an odd time for me to be writing, right? Well, turns out the weather decided to dump a bunch of snow, which makes the morning commute pretty crappy, so I had to get up a little earlier. But doesn't my rotation start soon? It does, but not until 9am today, because I'm going to be working at the ventilation clinic! 

And no, like my dad asked, it's not the "vent clinic" for the vent system at the hospital, no heating/cooling/air-conditioning. The vent clinic is for patients who are on ventilators and have out-patient appointments. So my preceptor said it's going to be a very busy day, and to bring lots of snacks (which I never object to). 

Yesterday was a fun-filled day of more calculations, but more-so to find a good bolus feeding routine for one of our patients. Right now she's receiving her feedings constantly, 24-hours a day. We're attempting (pending tolerance) to have her feedings given just 4 times a day in larger amounts. But, it's important to work around daily schedules, school, etc. Plus, there are only certain amounts that you can give someone a bolus at a certain time because of bodily rhythms and stuff like that. 

But, I should probably venture out into this lovely weather. GoogleEarth is showing that all the highways are yellow and red...aka slow and stopped. I will fill everyone in on the vent clinic soon...


................

Talk about filling everyone in soon - about 9 hours later to be exact!  


Vent clinic only runs from 8am-noon. Well, the last patients come in at noon, so I was actually only there until 2:30pm, seeing patients until about 2pm. It was definitely not what I expected, but, in a good way.


First, it was at an off-site clinic, so away from the hospital. Tough because I wasn't sure where I was going (and the lovely snow didn't help), but, I didn't have to park out and shuttle in, which was so nice! The team there is comprised of a social worker, a medical social worker, nurse practitioner, doctor, and the dietitian. Everyone works together for each patient, and every patient is seen by each member of the team.


It was very interesting, that while every patient was on a ventilator (or has been at one point), they all had different conditions. Muscular dystrophy, cerebral palsy, Tetrology of Fallot, diabetes, etc. My preceptor works part time and really enjoys her experience. Think of it...you get to know your patients really well because you follow them all the time and see them on a consistent basis, yet you get to practice the clinical science aspect of dietetics. Pretty sweet.


Getting home around 3:15pm was nice as well. I had time to make dinner and relax, but now time to start on homework for next week! 


Gettin' there...167 days..

2WD1

2WD1 = 2nd week, day 1

...and my brain HURTS. Today was full of calculating TPN/EN formulas for patients and it included a lot of math! Some of the problems were pretty simple, others were far more complicated. But, I do like being able to see patients and follow up with patients who have been here since last week.

Our ketogenic diet kid (aka: ketokid) left on Saturday. Her ketone levels were a whopping 4.3! So, hopefully that affects her seizures and they'll see a decrease in frequency and intensity. Hopefully the diet isn't too tough to follow though...

and...I'm so happy, but a patient I was following last week who was Failure to Thrive (FTT) and had C.diff (a horrible type of diarrhea bug that is usually contracted in hospitals) has finally started gaining weight. Her projected growth velocity is 25-35 grams per day (she's 16 days old), and between today and yesterday, she gained 85 grams! Hopefully that means she'll be able to go home soon. This is also the patient where when I talked to the mother, she was concerned about the baby's swallowing. Since this is outside of my realm of knowledge, I told her that I'd talk to her physician and suggest a swallowing consult with the speech-language pathologist. And, I paged the doctor and we spoke, and the baby was seen, and insto-facto...the baby gains weight!

It's just really refreshing to have physicians and other healthcare providers really take an RD's (or intern's) recommendations and concerns to heart.

BUT! Back to the math. Anyone wanna give one a try? Here's one of the harder problems I encountered today.

Patient A is on a track to go home. She's currently receiving a solution made from diluted Kids Boost Essential 1.5 to make it a 26kcal/oz solution. How many grams of protein are being injested if the patient is taking in 1500ml? And, if the patient is to get 1560ml of free water per day, how much extra free water must be given? (KBE is normally 45kcal/ml, has 42g pro per liter, and has 720ml of free water per liter)

Haha, give up? Don't worry, it took me a while...

Make it simple: 1500ml of a 26kcal/oz formula using 45kcal/oz formula

1. 26kcal/oz x 50oz (1500/30) = 1300 kcal (Finding out how many calories worth come from KBE)
2. 1300kcal/45kcal/oz = 28.9oz (Taking calorie info to find ounces used)
3. 28.9oz x 30ml/oz = 867ml (Taking ounces used to find volume)
4. 867ml solution x 0.042 (42g pro/1000ml) = 36 g of protein (Using volume to find protein!)

Not done yet!

If we used 867ml of volume, and there are 720ml of free water for every liter of solution...

.867 (percentage we have of one liter) x 720 = 624ml

If the patient needs 1560ml...(1560 - 624)...they need to get 936ml through an IV or water intake!


As you can see, this is why my brain hurts!! But it's definitely nice to get so much practice. Other than that, today consisted of following up on some other patients, many of who were in surgery or their parents/caregivers weren't available to talk, so there wasn't anything too exciting there. I just worked on case studies and TPN/EN calculations for the majority of the day :)

Week one was all epilepsy. It's amazing how many kids have seizures, sadly enough. But again, most of my week was devoted to calculating a ketogenic diet for our epileptic patient. By Friday, her ketone body levels had raised to 1.9, almost at the therapeutic level of 2.0! This was extremely exciting as she has been there since Monday. The patient really seemed to love playing with our name badges, so as a parting gift, we got her her own!

The bad news? She threw up on me yesterday morning. Lovely. It came out of nowhere. Luckily interns don't always need their lab coats.

But besides working with an epileptic patient, I had exposure to patients with various viral diseases, and also a patient with arthrogryposis. Don't worry, I didn't know what it was either. Google it!

...too lazy? OK. It's a rare genetic abnormality that causes muscle weakness and fibrosis. This causes the joints to curve to awkward angles, causing the patient to be wheelchair bound. It has no real link to nutrition, but we had a nutrition consult to the patient for other reasons.

And while this all can seem to come across as incredibly saddening and heartbreaking, the patients are completely different. They're all (95% of the time) in happy spirits, glad to be getting help. It may help that I am younger, and able to relate to them more easily. Yesterday I played peek-a-boo with a "ladies-man"-type 2 year old who was sitting inside by the window of his room and I was standing on the outside. SO incredibly adorable.

But now it's finally time for the weekend, so more to come next week!

KD's

So, I started Tuesday and today with  my preceptor that I will spent most of my time with until next Friday. She is mostly a general pediatric dietitian, but we've been spending a lot of time lately with a patient who was admitted to begin a ketogenic diet (KD) regimen.

Super interesting!

Our patient, who is into her teenage years, has been having about 15 seizures a day since she was born. So since medications haven't been all that helpful lately, her family and doctors decided to try out the ketogenic diet. Basically what this diet does, is that the high fat in the diet is the main source of energy, instead of carbohydrate and protein. Because of this, the high fat, or ketones, somehow alter the activity of neurotransmitters. And since this activity is altered, it has been seen in hundreds of studies to decrease the severity and frequency of seizures.

She was started on a 2:1 ketogenic diet. This means that she'll get twice as much fat and she does carbohydrate/protein. In a normal diet, it's the complete opposite. So it's not just that simple. This diet basically gives the patient no room for starch items. This means no bread, pasta, candy, cereals, etc. Plus, this diet has to be controlled so much that the patient (or caregiver) must weigh out their food to the exact gram.

An example of a 2:1 ketogenic diet to get a total of 1600 kcal per day would be:

65 g applesauce, unsweetened
28 g green beans, cooked
32 g chicken breast, no skin, cooked
18 g butter
21 g corn oil


Wait, did everyone catch that? Corn oil and butter. And LOTS of it. That meal alone has approximately 40 g of fat and each meal is about the same. Because it would be nearly impossible to obtain so much fat from solid foods, most of the time additional liquid fats are prescribed. This means that patients generally tend to drink pure heavy whipping cream, olive oil, corn oil, or melted butter in large amounts. And no, it tends not to be very pleasant, I'm sure.

So my role, as an intern, has been to design meals. This means that I have to calculate and decide what items to put on her meal and menus, but exactly how much, in grams. And it's not as easy as just adding more fat as I add more carbohydrate or protein, because I have to stay under a certain amount of calories. And each food has varying amounts of calories/protein/fat/carb so it's not as easy as it sounds.

But amazing exposure. U of M only gets about one ketogenic diet patient a month, and 50% of the time, the patient has been on it for their entire life and has it down and doesn't need much help from an RD. This means that KD's only have to be calculated and manipulated about once every two months. I'm pretty sure I'd never get this kind of exposure at another internship.



174 days...

Whoa.

Oopsies, talk about being NPO. It's not that I forgot, of course, but instead I was on a holiday break! Therefore, there would be nothing DI related from December 17th - January 2nd. But, now that I'm back, I'm officially in my clinical rotations!

Today started off well and I was ready to go at 8am with my pre-rotation case studies and homework all set. I met with a preceptor and we went up onto the floor and did rounds with doctors, pharmacists, senior residents, and nurses. This was really neat to see how the multi-disciplinary team functions and how the RD's are involved. They gave their input for TPN vs. EN nutrition, how patients are feeling, how they are eating, etc. 

After a 3 hour session doing rounds, we visited some patients. Unfortunately the patients we saw were "frequent fliers," or patients who spend a lot of time in the hospital.

One patient had rhabdomyocarcinoma, or basically muscle cancer, and unfortunately they don't expect him to make it much longer. He has very bad ascites, or fluid accumulation in the abdomen (from a lack of liver and kidney function), and they drain up to 5 LITERS of fluid each day.

We also saw a cute little girl who has cancer, a patient who has a leaky G-tube (a tube that you feed yourself through your stomach), and a few patients who need TPN orders.

Along with this, I also had some practice writing TPN orders (like my previous post...not so fun!). But, it was nice to have practice and as I go along, I'll be able to whip through them. I also had my first day and practice into writing a nutrition assessment note. This means that I had to assess the patients height, weight, BMI, fluid intake, food intake, appetite, bowel movements, basically everything! Then, I had to practice writing a nutrition diagnosis, which is much different from a medical diagnosis.

First of all, dietitians can't make medical diagnoses. For example, if a patient comes in the hospital and they're not eating because of all the cancer medications they're on. Instead of making a diagnosis of cancer (since I can't do that), I would need to make a diagnosis of inadequate intake. It all basically revolves around standardized language, which I'll just have to get used to.

Then, I make the nutrition diagnosis. After that, I make intervention recommendations, such as a high calorie, high protein diet or carbohydrate consciousness. I make notes on the monitoring and evaluation, which is very important. This is where goals for the patient go, which might include to increase weight, decrease blood glucose levels, maintain weight, eating certain amounts at meals, etc.

What a lonnngggg day! But, awesome exposure and I'm excited for tomorrow. Now, it's time to read up a little and refresh about epilepsy. Bring on the ketogenic diets!

How many days?? 176.