Restless.

I'm getting restless. The end of my internship is a little more than 3 months away, and I'm getting extremely restless. Especially with the end of my clinical rotation coming to an end here in a few weeks - I only have the rest of this week in the NICU, then a bone marrow transplant (BMT) rotation, a clinical nutrition management, and an elective week, then done. It doesn't help that I'm getting dehydrated every other day and my sleep schedule is always messed up from the weekends.

What is nice about being in a rotation for 2 weeks straight is that I get to see how my patients do over the weekend. It is even better when it's in the NICU because on Friday I helped the medical residents make the TPN orders. My little twin boys are doing great, their hyperbilirubinemia (high levels of bilirubin in the blood, which if it lasts too long, can indicate liver issues) has resolved, as well as they're continuing to grow! I have been assigned 2 new patients that I'll continue to watch throughout the week and make TPN recommendations on. This week I'm expected to be the one speaking up in rounds...exciting! The fact that I've taken the time to get to know the medical residents has worked to my advantage - it's made this part of the rotation less intimidating.

As far as my elective week, I asked my current preceptor if I could do my elective week in the NICU, and she turned me down. She said she thought I did great, but thought that it'd be in my best interest to do an elective week where I'd get more varied experience. So, I asked my preceptor from last week in the PICU, if I could do my rotation there, and she accepted! One less thing to worry about at the moment.

For the elective week, I can basically go anywhere and/or do any rotation. Which means I could go to another hospital or facility and complete a week there. The only issue with going to another facility is that I feel like it'd take me 2-3 of the 5 days total just to figure out their charting system and find my way around. Plus, I really enjoyed the PICU rotation as well as the preceptor for that rotation, and of course I'm sure there will be some interesting patients for the week.

Anywho, just another day gone...looking forward to tomorrow because it's Tuesday and that means I'd only have 4 (full) days left of this rotation. I'm so looking forward to finally be getting a paycheck...hopefully?

95 days.

Found my FAVORITE rotation!

Ok, so I know, I know, I always say each week that the particular rotation I'm in is my favorite. But now that I've been in all but one of my rotations, I can easily say that I have actually found my favorite rotation.

The neonatal ICU.

It's by far my favorite. These little babies are no more than a few weeks old and are so tiny, and they have the most complex nutritional state of any patient I've seen this entire year. While their nutritional status is so complex and mostly all require TPN, it's also very standardized as far as what to do next. Yet since the patients are newborns, they have clean slates. No complex history but with a million times more potential for improvement. 

Not to mention, the preceptor for this rotation is one of the most challenging. I have daily homework and case studies, as well as daily lectures on topics such as formula feedings for premature babies, to TPN, to specific disease states, etc. The preceptor challenges me, has me talk up to attending doctors and residents during rounds, and even teach the medical interns how to do TPN. There's seriously no faster way to learn TPN than to have to teach it to medical school graduates! But, yet again it's very rewarding and assuring about how much I have really learned this year. Before this year, well, in the last few months really, I was so unsure about TPN calculations. It's easily one of the most difficult things to do in dietetics. I really always wonder if I would have gotten this much experience at another hospital.

Anywho, if anyone is wondering (is anyone out there?!), my presentation on argininosuccinic aciduria went well. I'm so happy it's over, and I can finally have one more thing on my list checked off. The  next thing I have to work on is my written case study, which is due on the last day of my entire clinical rotation, so the end of April. Needless to say, I'm going to take the weekend off...well, besides my homework/case studies/reading for the NICU.

Happy almost Friday! 99 days left! 

Littttttttle babies!

And when I say little, I mean little. How much did you weigh when you were born? Personally I was 7lbs and 7oz, or in metric terms, about 3.4kg. The little babies I'm working with weigh anywhere from 600grams to 2.5kg or in other words...babies as small as 1.5 pounds.

These babies are all preterm babies, or born earlier than 38 weeks gestation. They may have been born early due to some sort of birth defect, an injury/event to the mother such as a car accident or such, been a high-risk pregnancy due to pre-eclampsia or gestational diabetes, etc. These babies are almost always put directly on TPN and are slowly transitioned to enteral feedings, or tube feedings. I don't have too much to say, mostly because I think I'm still processing the long day and the time really seemed to fly.

This rotation requires daily homework that is assigned the day before. So every night I have a list of questions or calculation practice questions as well as 1-2 scientific articles to read. Today I got to the hospital around 7:15am and didn't leave until 6pm. YAY. I also have a daily lecture that covers a multitude of topics. Today covered the basics of prematurity as far as gastrointestinal issues, feeding guidelines, classifying "premature" vs "pre-term" vs "late term" and knowing birth weights and having to classify them by weight class and plotted percentiles.

All I know is that this week is crazy-busy. Not only do I have daily homework and readings, which I really don't mind, but I'm trying to prepare for my oral case study as well. It's on Wednesday and I have to plan on presenting, by myself, for about 45 minutes. Needless to say, I'm keeping this one short.

 

Now onto the NICU

So my week of renal is over! As I mentioned before, it's just not my thing. But, needless to say, I learned so much. I always like to give my homework case studies a good attempt before I actually go into the rotation, then revisit them on Thursday before they're due. It's amazing how much I seem to learn in such a short amount of time. While some questions may stump me on Sunday, I can whip through the case study by Thursday. 

Today I saw some crazy disease states though. Google "Pearson Syndrome." It's a rare syndrome where the body's DNA for the mitochondria isn't correct. Therefore, it results in about 5 different other problems such as anemia, pancreatic insufficiency, liver/kidney failure, and metabolic issues. These kids rarely live past infancy because of all the complications. And get this, in it's entire history, there have only been 80 reported cases worldwide. SWEET.

But wait - make it 81. That's right, we have a Pearson Syndrome patient at Mott! And she's 7 years old. She has definitely defied the odds. Her medical history is crazy, fit with 36 different medications that she takes every day. Thank goodness for her amazing parents and siblings, she's so adorable. She was in for just a routine out-patient procedure, but for with her intense medical history, she was admitted to do a little more monitoring.

I'm getting more and more anxious about applying for jobs. I used to job search for "fun," just to see what's out there, what areas seem to hire more, etc. Now I have to start taking it a little more seriously and consider if I want to apply or not. In a few weeks, we have an intern meeting that is based on resume building and interview skills. I don't think I'm going to start applying until after. 

The spring-like weather has me feeling like I did during undergrad in the spring semesters - aka: almost DONE.

Gettin' there...

So I know I haven't written much this week, but honestly, it's not my favorite rotation. Don't get me wrong, I think the renal population is very interesting, but I've come to the conclusion that I don't think it's for me. And maybe it's just that a lot of the patients this week weren't overly complicated or needed much nutritional intervention, and maybe it's just more that I needed more time with the population. I'm a little jealous of the adult interns because they get to spend 2 weeks with the adult renal patients.

But anywho, needless to say, it's almost Friday. All-in-all, the week went really well, I really enjoyed being able to be in the clinic setting again, but also having in-patients. I also thought my preceptor was awesome, she was really laid back but very knowledgeable about renal patients. While I am bummed that I didn't get to spend tons of time with renal and that we didn't have a ton of interesting patients needing crazy nutritional intervention, I am very excited to go the NICU next week.

This will be by far my most challenging rotation. Other rotations have pre-rotation homework that's due on the first day, along with reading, etc., etc. This rotation has a day-by-day homework assignment and readings. Not to mention that my oral case study presentation is next Wednesday, which has to be about 45 minutes long. I'm not going anywhere this weekend so I can prepare. I'm really excited about this rotation, and so happy that it's 2 weeks long.

So not only is it the NICU rotation and my oral case study presentation, on Friday myself and the 11 other interns are doing a big presentation/game at the Nutrition Specialty Day in front of all the dietitians/directors/dietetic students. We're going to be playing an interactive game based on the National Nutrition Month promotion of "Eating Right With Color." 

It's going to be a c.r.a.z.y. week. But for now, that's all. The warm weather today helps remind me that I'm almost done...I'm gettin' there. Week-by-week. I'm really starting to miss everyone back at home and school...I can't wait until I can get a big-girl job and a paycheck and be able to come home from work and just be HOME but not have homeWORK. And I can go visit family and friends on the weekend and not have to worry about pre-rotation readings and case studies. Rawr.

106 days left!

I love you with all my kidney :)

My two week rotation in the PICU wrapped up without too many glitches. It was a good week, with patients getting better and moving out to the regular floors and coming off ECMO treatment, which is always a great week. What I find fascinating is that a lot of our patients come in with simple complaints: stomachaches, fever, night sweats, but they end up being life-threatening and/or even lethal. For example, one of the patients in the PICU last week came in with vomiting and it turns out it's possible she has stomach cancer.

The ICU setting is by far my favorite area. It's challenging and very biochemical, yet the team atmosphere and approach lends itself to learning something new every day. I've already experienced the PCTU, the PICU, and my last 2 week rotation will be the NICU (neonatal intensive care unit). That rotation will be 2 weeks long as well.  I'm really looking forward to that one!

Ya know what's crazy? Including this week, I only have 6 weeks of my clinical rotation left. AHH! This week I'm working with pediatric renal patients - so kidneys all week! It's interesting how different specialty areas are. Last week in the PICU our patient list was 60-some patients long, and this week it's on average ~4-6 inpatients. But in addition to this is the outpatient clinics which can be anywhere from 2 patients to 12. I think this is an area that I'd really like, working with both patients in and out of the hospital. The inpatients bring about challenging biochemistry and medical nutritional therapy. Yet, when working in an outpatient setting, it brings the ability to really get to know your patients and see them grow up and (hopefully) stay healthy!

Other than that, I'm just working away on my oral and case studies. Think about a case study done in undergrad and now think of it done on an actual patient, someone that you make direct interventions and recommendations for, and times the difficulty of the paper and presentation x 183,295,752. But, that's exactly why they give us about 4 months to find two patients and begin the paper and presentation. The paper and presentation have to be on two completely different patients so there is a lot of opportunity for learning! My oral case study is going to be on argininosuccunic aciduria and my written case study is going to be on ECMO therapy as life support in calcium channel blocker overdose.


I can't believe how fast this year is really moving...I'm going to be applying for jobs here in a few weeks - YAY! 


109 days left!!

Second week in the PICU

Yep, second week in the pediatric intensive care unit. It was good to be able to see the same patients after the weekend, especially since so many of them took turns for the better and are being extubated, getting off TPN, moving to tube feedings or oral intake, and even better - being moved to the regular floor. Not one of my patients took a turn for the worse over the weekend. YAY!

So, since there's not much to report there, I'll talk about something else. For those who have applied for internships and are awaiting your fate in April, if anything, especially if you haven't started, start saving NOW. Remember the initial estimate of what my finances would result to by the end of the year? Yep, totally bypassed those a long time ago. I mean, it doesn't help that my initial estimate for the price of gas would be (at most, ha) $2.80 a gallon, and now it's rounding $3.60 a gallon. Plus, the many car repairs that I've had to endure are now coming to be about $1,200 for new brakes, oil changes, wheel bearings, tires, etc. And of course it doesn't help that the internship is unpaid. My average monthly gas bill is ranging around $180-220, but I can't complain because of the fact that I'm living with family and living for free.

But, ya know what - it's something every dietetic student must endure. Yes, some internships have a stipend, but many of those with stipends are in the most expensive cities in the United States. And...many of those with stipends require 6-8 years of commitment to the organization after you graduate, mainly internships with the military. Which, if someone is interested in that career choice or is already a part of the military, it works out perfect! I've heard great things about military programs and VA programs, and I've definitely always been interested, but, I know that the U of M internship would give me mounds more experience and exposure to disease states and cases.

Anywho, not to freak anyone out, but I know that when I was applying, I told myself that if I got my first choice internship, that I wouldn't work that summer and just completely relax. I did get my first choice, and I'm so incredibly glad that I decided to still get a summer job. It helped me feel a little less guilty about going out during the summer and my bank account loves it right now. Well, it's not exactly loving life right now, it's struggling a lot, but I have less than 4 months to go and (hopefully!) I'll be able to get a job and start building it up.

Real life of an intern - time is flying and bank account is draining - but I'm loving every minute :)

115 days left! 

Crazy. Week.

Ok, so I know I haven't written since Wednesday, but in my defense - this week has been hellacious.

First, we currently have 3 patients on ECMO. THREE. Usually during a normal week, there might be one patient on ECMO treatment. What makes it even more interesting, is that one of the patients had an intentional overdose on an extended release calcium channel blocker. What this means is that since she took 30 of these pills, they're taking forever to filter out of her system. She's not only on ECMO, but also CRRT. As far as nutrition goes, she's being pumped with 960 grams of dextrose every day. As a normal person, we consume anywhere from 200-300g/day. From research, it seems as though calcium channel blocker medications, when taken in excessive amounts, has a hypoglycemic effect (makes blood glucose very low). So while we're pumping her full of dextrose (another word for sugar/glucose), her blood glucose levels are still low! Not to mention she's on TPN, which means we have to match the sodium as well, so she's getting over about 560mEq. This is like eating a diet that has 13,000mg of sodium per day!!

So, needless to say, I chose this patient for my written case study. But, overall this week I have been exposed to more disease states than I ever imagined. I'm still in an ICU setting, but whereas last week was with one specific patient population with cardiac (heart) issues, this week and next week are just catch-all as far as disease states. We've had 2 intentional overdoses, liver transplant, hypoxia, renal failure, polycystic kidney disease, diabetic ketoacidosis, severe bladder infections, CRRT, ECMO, Steven-Johnson's syndrome, San Filippo-A, sickle cell anemia, and many more. If you're looking for something to do, looking those up on the internet will definitely give you something to do.

Something that I do wish I learned more of in undergraduate work is writing TPN's. I really can't recall even being introduced to what TPN was, well, past what the acronym stands for (total parenteral nutrition). It's such a huge topic and has so many parameters and it does take a long time to get a grasp on, so I do understand why it's not focused on too much in undergrad, as it would take a lot of time to cover. Maybe that's an idea for another class, is a class based solely on TPN. But, just a thought...

Since Wednesday was crazy as it was, I just ended up going home and relaxing, free of internet use. But last night, I went to a presentation compliments of Nutricia. And I say compliments because it was at a super fancy restaurant where they had filet mignon and cabernet wine for dinner, all free of charge. It was a presentation that wasn't required by the internship or anything, but it was advertised for RD's and interns and it helped that it was in the same town I'm living in. The presentation was on "Nutrition in eosinophilic esophagitis (EoE)" The only downfall was that it was so late at night and I ended up taking my (super delicious) blueberry cheesecake to go.

But luckily the weekend is here, and I look forward to relaxing and not having any pre-rotation homework to do, as I'll be in the same PICU rotation next week.

Peace. Love. Internship.

3 procedures in 1 day!

While the rounds were four hours long this morning, I saw three medical procedures take place! 

1. A year old little boy being extubated (taken off the artificial breathing system)

2. A Dophoff feeding tube being placed in a teenager (for tube feedings)

3. ECMO (artificial blood oxygenation system)

The first, the extubation, was very anticlimactic but incredibly interesting nonetheless. It was a little 1 year-old boy who had been on a vent for about a month or so. He was admitted for seizure activity monitoring and then had some complications with that. Basically there was 2 nurses, 1 attending doctor, and myself in the room. They got a bunch of drugs ready just in case the patient had problems with the extubation or the patient starting to have respiratory arrest or even cardiac arrest. They starting taking out tubes one by one and then quickly slipped out the respiratory tube. The patient was squirming with agitation and crying and while this is sad and hard to watch, it's a really good sign - only because it's good to know the patient is still conscious and has full feeling and no paralysis. This procedure wasn't as intense as I was expecting, but then again, the patient was extubated without any problems, which is a good thing!

Secondly, I saw a tube feeding being placed, which was extremely interesting. First is deciding where the tube is going to go once it's in the digestive tract. The end of the tube can either hang out in the stomach and the formula will be dripped into there, or it can be placed past the stomach and into the jejunum (the area of the intestines right past the stomach). These are used for patients who are at aspiration risks and especially those who are on ventilators. When a patient is on a ventilation, especially CPAP which has really high pressure on the stomach, it's important to put the tube as an NJ tube (nasojejunum - in through the nose and into the jejunum) so the patient doesn't have the formula come up and either vomit or aspirate into the lungs (which would cause pneumonia or infection). 

First, the tube was covered in a little bit of lubricant and was fed through one of the nostrils. The patient was then told to drink from a juicebox to help guide the tube down. What stinks about it is that I could tell the patient was incredibly uncomfortable, I can't imagine it'd be a great experience. I can't stand the feeling of having a hard booger in my nose but let alone a massive tube being fed down into my stomach. To make sure the tube is in the right place, they go to radiology to have an x-ray done. It's important to do this to make sure that the tube didn't end up in the lungs by accident, isn't coiled up in the stomach, or made it to the right place. 

Lastly (phew!) I saw an ECMO machine in use. ECMO stands for "extracorporeal membrane oxygenation," which is just a long word for a machine that takes blood out of your body, runs it through a machine and oxygenates it and/or helps your heart pump the blood by running it through a membrane, and then feeds it back in. What was craziest about this machine is that the tubes that take the blood out and put it back in is like half an inch wide and takes blood from the patient's leg and puts it back in the neck. I went back later to get a "tour" from the tech working the machine. Yes, there is a technician that sits there 8 hours a day and constantly monitors the machine.

Back up, this machine is MASSIVE. It stands what seems like 8 feet tall and is about 3 feet wide. They monitor hematocrit and glucose every hour, as well as clotting time. The clotting time test was really neat as well. They put about 4mL of blood into a vile that has broken glass inside and the amount of time that the blood takes to begin clotting the broken glass is the clotting time. This is important to know because they put heparin (anti-blood clotting medication) into the ECMO machine to keep the blood from clotting within the machine. The University of Michigan hospital is one of the few hospitals in the Midwest to have ECMO machines. It's kind of a "last resort" for respiratory and/or cardiac failure. Sadly, the patient who was on it today was a previously healthy little girl who was exposed to H1N1 and it turned into a super-infection that started to cause multi-system organ failure...

Anywho, today was a long day. Tomorrow will be another day full of procedures as I will watch a TPN solution be made first thing in the morning. I've always been really interested in how it's done! I'll report on that tomorrow.

122 days left...