PICU

While last week I was in the PCTU, for the next two weeks, I'll be in the PICU. Yep, take a second look, they're two different things! The PICU stands for the Pediatric Intensive Care Unit. Unlike last week where I was working mainly with kids with congenital heart problems and other cardio throacic issues, the PICU is more of a catch-all for general intensive care. For example, a lot of the kids with bad rashes, infections, surgeries, etc. My daily tasks will include medical rounds for 4 hours in the morning (yikes!), followed by taking care of consults, assessments, reassessments, and length of stays. A "length of stay" is when a patient doesn't have a nutrition consult in and isn't at high risk, but it's still good to check in with them about their diet/intake/appetite within 3-5 days or so.

Along with the PICU, for the next two weeks I'll also be working with birthing women. Unlike most of the patients in the hospital, these patients are on a consult-base only...so I won't be seeing everyone, only those who might have gestational diabetes, not eating well, hyperemesis gravidarum (really bad morning sickness), or who come in with previous health conditions that might put their pregnancy at risk. But at most, we might be seeing 1-2 patients who are birthing moms. Lastly, during this rotation I'll also be covering kids who are in for physical therapy. There usually aren't many of these, and they're more of length of stay consults. This is because most of them are in for general physical therapy and don't have any eating issues. If anything, we're trying to get them to eat more so they can heal faster and have enough energy for their therapy.

But seriously? I can't believe that I have 4 months left of my internship. It seems like it's gone by so fast, yet it still seems to take forever. It's going to be a weird feeling of being in the same rotation for two weeks, but it'll be nice not having as much homework this upcoming weekend. 

I also have to give a shout-out to everyone who applied for internships a few weeks ago. I can't believe it's already been a year since I applied! Seriously though, you can't think about it too much until a few days before, or you'll drive yourself insane. Just like every weekly rotation, while I may start preparing for homework and readings the week before, I can't look too much into specific medical conditions. Mainly because I have NO idea what specific medical conditions I'll be seeing, and also that the rotations are a learning experience and it's important to go into each week with an open mind. Being flexible, open-minded, and prepared are MUSTS. Haha, "musts," that's a funny word...

Take over x 2

Well, I’m almost halfway done with clinical. Crazy. This week was definitely a whirlwind, being in the PCTU (pediatric cardio-thoracic unit). Remember Tuesday? When I had a super long day because I basically took over my preceptors entire position while she was gone? Well, I did it again today. But this time, with much more success. I actually went to rounds by myself and made it through those alive, updated all the patient forms, caught everyone up on the sheets as far as weights, intakes, TPN orders, and formula orders, and then wrote a few notes.

And I know for a fact that I learned a lot this week, because during rounds I caught that the addition of a specific drug would put a patient over his fluid requirements for the day. In this population, that’s extremely important. So, because of this, I made a recommendation to decrease the volume of his TPN order, which was exactly what happened! It was such a good feeling.

Throughout this rotation, I came across so many different congenital heart defects. From as basic as ASD/VSD (atrial/ventricular septal defects), which are basically a hole in the heart, to patients who have only one ventricle (so the body basically gets no blood), D-MGA (malposition of the great arteries; so basically the arteries are switched and your lungs get oxygenated blood and the body gets unoxygenated blood), and so many more! Usually these kids come along with a lot of other anomalies as well, from scoliosis to heterotaxy to having only one of an organ, like a kidney, or two of an organ, like a uterus.

That is what’s amazing about this internship, is the patient population I’ve been introduced to. I’ve seen so many crazy medical conditions. I’m seriously searching medical conditions on a regular basis, internet search engines and I have become great friends. Thinking about internships and wondering where to apply? If you really enjoy a challenge, definitely consider U of M!!

Take over?

So why didn't I post anything yesterday? Probably because I was utterly exhausted. Since my preceptor was gone yesterday, I did the entire position all by myself. Yep. Everything. I did the daily monitoring, reassessments/assessments, TPN orders/recommendations. Let's just say that my brain hurt. It was good to know that I understood everything, but just the daily steps and tasks and in what order threw me off. 

But if anything, this rotation has exercised my practice with TPN the most. Especially the way that it's ordered and how to regulate labs with what's in the order. I learn best by being thrown into things and finding my way out by learning how things are done, and that's completely what this preceptor did yesterday. I really don't think I'd have as much improvement with my understanding of TPN if it weren't for yesterday.

Luckily my preceptor was back today. I was able to ask questions from Tuesday and get feedback. After going to rounds again this morning, it wasn't quite as overwhelming as it was on Monday. I finally got the idea of what to listen for, what to write down, what to be thinking about. I'm excited for tomorrow as I think I'll be able to think of recommendations as we go along. It helps a lot more too that I'm getting a better idea of each patient, what their medical issues are, what they're nutritional past is, etc.

Otherwise, I'm just getting ready for the weekend. I get to take my car into the shop again. GRR. Just what I need is 60 hours a week of unpaid work and my car acting up. It's wonderful. *Insert sarcasm*

It's crazy to think that I'm almost halfway through my clinical rotation already. These weeks are really flying by. It seems as though I just start one rotation and then a few days later I'm emailing my preceptor for the next week and starting the homework. Although I'm not complaining! The faster this internship goes, the more I learn and the earlier it seems I can start applying for jobs. 

Anywho, what's even better? 128 days.

PCTU

After my body seemed to shut down on me on Friday morning and making it through work that day, I slept for a whopping 12 hours! I went to bed at 7pm on Friday and didn't wake up until 7am on Saturday. And...it felt wonderful, I felt so much better. There seems to be a bug going around the house where I'm living. The little ones are always getting sick and it never seems to stop, it just makes it's rounds between us all.

Not to mention we got dumped with another 10" of snow yesterday. Lovely. At least I didn't get stuck in the driveway this morning, I was smart enough to shovel the driveway before I attempted at getting out. While reversing out of the driveway, I just gunned it to the floor and made it out to the road, which was sadly unplowed. Even the highways weren't plowed! It took me about an hour to get to work. I was a few minutes late, but my preceptor definitely understood. A handful of the interns ended up getting called into work in foodservice, but somehow I didn't...

I also had my literature review today, which I'm not sure if I've mentioned before. It was an hour long presentation that reviewed literature on a specific topic, and it's completed with a preceptor. My topic was "Estimating REE (Resting Energy Expenditure) in Obese Pediatric Patients." Basically, there are about 5 equations that are used to estimate the bare minimum amount of calories needed to keep our organs going. The equations use our weight, height, sex, sometimes race, and other factors to determine our caloric needs. But, when a patient is super-obese, it can estimate that they need like...4,000 calories! Which, would probably only fuel the problem. So, the literature I reviewed (which there is basically nothing out there) and pointed out it's strengths and flaws, and so-on and...yeah. It was in on of the main auditoriums in the hospital and I had an audience of about 15-20 people, so...good practice!

This week I'm in the PCTU, or pediatric cardiac-thoracic unit. The population is little tiny babies, averaging a range of one day to 6 months. They're so tiny and cute! Most of them have congenital heart anomalies, which are surprisingly common in babies. This is going to be one of my most challenging rotations, not only because the caloric and fluid needs are so limited, but because all patients are either on TPN or tube feedings. The case studies were already more brutal. I'm definitely glad I made it into work today because I've already learned so much. I really like this preceptor, she challenges me - which I really enjoy. 

So, I need my sleep because obviously by Thursday my body likes to shut down on me. This internship is so brutal when it comes to time consumption and sleep deprivation! Not to scare anyone out there...but I'm definitely getting my monies worth and exercising my undergrad education. The biochemistry, mammalian physiology, MNT (medical nutrition therapy), and advanced nutrition are coming in handy! 

Anywho, I.AM.OUT....

Rough.

I'm ready for this week to be over. I'm just exhausted. 

This week has been full of running all over, going to meetings, leaving one meeting to go to another, finishing up case studies for the current week, starting readings and case studies for the next week, preparing for my literature review presentation on Monday, getting evaluations done...yatta yatta. 

I know I'm sure I say this every week, but I am really enjoying the rotation I'm in currently. It's a mixture of inpatient counseling for newly diagnosed diabetics, outpatient counseling for liver transplants, and also inpatient eating disorders. There's always something to do or a patient to check on, but it's never overwhelming. Every patient is seen and task gets completed by the end of the day, but there's no need to rush.


As for my oral case study subject that I'm keeping a close eye on, I'm just trying to get him to eat anything! Today I took him a tray of multiple supplements, hoping that at least one of them will spark some interest so he doesn't have to go home on a tube feeding. I took him Carnation Instant Breakfast, Mighty Shake, Boost Kids Essential 1.5, whole milk, 2% milk, soy milk, and vanilla pudding. There's got to be something in there that he likes! He's the complete opposite of many of the kids in the hospital, or even adults for that matter. We need him to eat! ANYTHING! I'm encouraging his mom to add butter and oil to foods for additional calories, to purchase high fat, high protein foods to get some meat on his little bones. But overall, this little boy is the cutest little kid ever and is so animated. Did I forget to mention I'm incredibly excited to be back in pediatrics?


But tomorrow should be a lot slower paced. Fortunately/unfortunately, my little buddy is hopefully going home tomorrow, but I'll miss him. Hopefully he just continues to eat so he continues to gain weight. I'm very excited that it's almost the weekend. I feel like this week has taken a chunk of my life out of me. Next week is going to be equally crazy. I'll be in pediatric cardiology, in which I have to be there at 6:30am! It's going to be a long week full of an incredible amount of TPN practice. Which may be challenging, but I'm going to have to learn the trick of the trade. So, bring it on! 


So. Tired.

Liver Transplant Clinic

...is where I spent the majority of my day today. The liver transplant clinic is for patients who wish to be on the transplant list, who are already on the transplant list, or who have undergone a liver transplant. And of course, they're all cute little kids! 

It's interesting how many of these kids have the same diagnosis (mainly biliary atresia, treated with Kasai procedure or liver transplant), but their cases are so completely different. Not only in terms of nutrition, but different cases when it comes to social work, psychology, diet, medications, overall lifestyle, etc. For example, one of our patients was very compliant, taking medications and had a great support system. His liver transplant will most likely give him no complications in the future and he'll lead an overall healthy life.

Then, there are patients who are extremely non-compliant, despite the fact they've had a liver transplant, or even had TWO liver transplants! Poor diet, lack of exercise, extreme weight gain, super-obese ranked BMI and non-compliance with medications. It's amazing, but...you can't help someone who doesn't want to change. That's one thing that I've realized since being in the internship. I have the extreme desire to want to help people change their lifestyle, but if they don't want to change...it doesn't really matter. What I say will most likely enter one ear and exit the other.


But, on a better note - the patient who I chose to do my oral case study on is doing well. He's SO incredibly and utterly adorable. He's eating more and trying more protein-rich foods. He likes to wave and blow kisses, and "roar" like a tiger. 


Did I mention I love this internship? 136 days...

Love...

Yep, it's good 'ol Valentine's Day. And I must say...mine was wonderful. 

Starting every new rotation as a dietetic intern is an interesting experience. Most of the time, I'm meeting my preceptor for the first time. Their note-writing format is unfamiliar, their patient base is unfamiliar, and the need to make a good first impression is key. Needless to say, my preceptor this week is amazing. She's very laid back but incredibly intelligent. Forgot to mention - I'm back in pediatrics, which makes this week even better. But, my preceptor is mainly in charge of patients who are newly diagnosed diabetics, liver transplants, and eating disorders. Today we only had 2 patients to go and see. One who was leaving today, and another, who I ended up choosing as my oral case study subject. 

The oral case study is a huge presentation that every intern has to complete solo. It's a 35-45 minute presentation covering a specific patient that we personally deal with and follow, covering bases of disease state, history, treatment, outcome, prognosis, etc. The patient I chose is under 5 years old, just received a liver transplant because of a rare genetic disease known as argininosuccinic aciduria. It's a disorder that leaves out an important component in one of the metabolic processes, causing an increase of ammonia in the blood. The high levels of ammonia in the blood causes developmental delays, sometimes even death if it's not caught early.

But besides my great first day of this rotation, I received beautiful flowers from my love. No better way to arrive back after a long day at the hospital.

The only thing that could ruin this day? My car. The fact that this car is 2,948 years old and it's been a crazy winter aren't helping the fact that my car needs to make it through 5 more months, at least. GRR. Anyone have a nice, smooth-running car they wanna donate to my cause? That would be wonderrrrfullllll...

PSYCH!

...is exactly where I worked a lot today. It's weird to think sometimes, while working at the hospital and being around all these foreign and crazy disease states, it makes me feel incredibly blessed to be "normal." Some of the states I've seen this week are:

Depression

Schizophrenia

Bipolar disorder

Eating disorders

Suicidal ideations

Panic disorders

PTSD

Phobias (today I saw aquaphobia - fear of water!)

Obsessive compulsive disorders

...and many, many more!

Now, most of the patients in this area are screens, but it's important to see if they have any intake issues while they're at the hospital. Again, it's just a whole different patient population.

Tomorrow is finally Friday.

Cardiac medicine = tons of education opportunities.

Which, is nice. Some patients are more receptive than others. I met with a really nice old man who took my education to heart and I could tell he had every intention to be proactive with his diet. But then again, I met with a woman in her 30's, with heart failure, who seemed to not care less.

This rotation has exposed me more to the ICU than any other rotation. Which is very rewarding if a patient improves and is able to move to more moderate care and then eventually go home, but it breaks my heart when during rounds the doctor basically told a family that their brother/son/father was brain dead. It really makes me appreciate everyone in my life and especially my health. It really makes me want to spread the word even more about the importance of a healthy diet and lifestyle.

As well, while all of dietetics is science based, cardiology seems to be more of a mystery in which you have to take clues and find rhymes and reasons for them. Take for example one of our patients, who had no previous medical history, but came in after a heart attack. She virtually eats nothing all day, but consumes 2 liters of regular pop and ice chips all day. She complains of hunger but doesn't like to eat much. She has a history of goiter and hypertension.

What types of things does this make me think of?
Pica - the urge to eat abnormal things such as dirt, clay, ice chips, etc. Usually due to an iron deficiency.
Diabetes - extreme thirst causes diabetes to help excrete excess glucose in the blood.
Goiter - iodine deficiency, lack of sodium in the diet (99% of table salt has iodine in it to prevent goiter).
Hypertension - basically too much fluid retention, which can be caused by high sodium intake, so we can't just supplement sodium to decrease changes of goiter.

SO...lots to look at. But these days, my days are super long and it seems like my brain is working 3,502,895x overtime. During the middle of one week, I have to start preparing for next week. Especially when this week's cardiology rotation came with a whopping SIX case studies and 4 pages worth of vocabulary/medical terms to look up/study/research.

I'm ready for the weekend.

142 days...

So I know I haven't written much since the "huge" snowstorm last week, but since many of the dietitians couldn't come to work, we had a lot of catching up to do on Thursday and Friday. But, I can't say there was much to note that I hadn't already. I did some bariatric diet educations and wrote notes, but I did come across a few interesting disease states. Search "Mullerian agenesis." Crazy.

But surprisingly, I really enjoyed GI surgery. I could definitely see myself working in this area. It just seems as though there is such amazing variety of patients and disease states. Not to mention, for those who undergo bariatric surgery and I have to do a follow-up diet education, those patients want to be there. They are so optimistic and excited to be receiving education. 

Anywho, this week is my last week with adults. I am in the area of adult cardiology. Today I had a great variety of patients, nothing too crazy or out-of-the-ordinary. I wrote two notes by myself, one on a patient who was in the ICU and on a ventilator. If a patient is on a ventilator, it completely changes what caloric predictive equation is used and there are many things that have to be taken into consideration, such as infection, fluid status, and medications. That's a big thing with this cardiac population is fluid levels. It seems as though, if I do educations, a lot of it will be on cardiac diets and low-sodium diets.

We did meet with a very cute elderly man who was very interested in our low sodium diet education. He had such good intentions to transform his lifestyle and while we were there he was making lists. This is the part I'm going to miss about being in adults, is talking to the patient directly and doing the educations with them versus the patients. But don't get me wrong, I'm super excited to get back to pediatrics. After this week, it will be kids here on out! YAY!

JK!

Just kidding! We definitely didn't get the massive amount of snow that they had predicted. Of course, we got lots of snow, but not the 13-24 inches they seemed to take a guess at. But it wouldn't have mattered either way, because as an intern (at least at U of M) there are no snow days. And instead of a regular day, all 12 interns were called in to be "emergency staff" in the food service area. Because of this, I stayed in Ann Arbor for the night at another intern's apartment.

What does this all mean? I was walking a mile to the hospital at 4:30am. Yep. In a blizzard.

But, it was nice to be back in the kitchen and to see all the staff again. I didn't end up doing much, just helping things get set up and waiting for regular staff to come in. I only ended up working in food service until about 7am, then I went back upstairs and resumed my regular clinical rotation.

Except for the fact that my preceptor wasn't able to get to work because of the crazy snow! So, I was kind of in the professional staff experience all over again where I had to get everything set up, decided who needed to be seen, for what, if it was urgent, etc. I got to see all but one patient, and that's because it was getting late and their assessment technically isn't due until tomorrow.

Sadly, I didn't have too many crazy patients today. I had a few diet educations on low fat diets and Dumping Syndrome. This syndrome is characterized by bad diarrhea almost immediately after eating a meal. Patients get this because of surgery they have on their stomach, which decreases the ability for a sphincter in your stomach to open and close properly. The patient I saw had a Whipple procedure, which is where the head of the pancreas is removed because of cancer.

Anywho, I'm extremely tired tonight. All I know is I am super tired. 145 days...