Endless consults and what's next!

Today was a busy busy day. Every year, about this (exact) time, the medical school interns graduate. This means we get a new batch...and they are all so excited and anxious and ready to change the world of medicine. But, this means that I'm getting consults for some rather interesting things. Such as a patient vomited after a feeding, when in reality, after speaking with parents, it was normal spit-up. Or that a patient had decreased intake a day before being admitted to the hospital, when in fact they had meningitis.


After looking back at the internship, if I could offer any advice to future interns and/or students...is to not lose sight of the basics of nutrition. Like serious basics. I'll take it back to the beginning. We have a new dietetic technician (DT) at the hospital who is new, younger, and has a good nutrition background. The DT's at the hospital are the ones responsible for inputting the calorie count information, computing the total calories and protein consumed, then relaying that information to the proper RD.


I got a page regarding one my 5 year old patient who is admitted for a bone marrow transplant, saying that she ate 320 calories and 90g of protein. Before you think that it's weird for a 5 year old girl to consume 90g of protein (which is a) true, b) more protein than I consume), what's the first thing that's wrong with this picture. It's so easy that it's difficult to see...


4 calories per 1 g protein. The most nutrition math out there. 90g protein = 360 calories. Not to mention the patient had only consumed 4 rolls with butter, 3 Andes mints, a handful of Goldfish crackers, and a candy necklace. I know, I know. I might just be ranting here. But it's the basic knowledge, but when it becomes a deciding factor if a patient needs to be put on TPN (which brings a wide variety of risks and possible complications), it makes a big difference. 


Whew! Off my soapbox.




So what's next in store for me? Well, since I ranted a bit above, I suppose I'll just make an easy list:

• Graduate on Friday!
• Celebrate my birthday with family and friends on July 4 (yes, that's really my birthday!)
• Start my new job on Monday, where I am now, filling in for RD's who go on vacation
• Summer bucket list
• Skydive
• Run/train this summer for the Chicago Half-Marathon
• Buy a new wardrobe (I still wear clothes from middle school!)
• ...more to come later J

Well, here it comes...1 full day left! Yayyyy! 

Wait...2 days to go...what?

Finally...down to the final couple of days. I started this countdown on September 8, 2010, and it was a whopping 296 day countdown. I'd love to say that it flew by, but it really didn't. I felt each day, each rotation, each evaluation, each project. I'm incredibly ready to be done.


But, looking back, there's no way that I can imagine going straight into an entry-level position without the internship. The things that added on to what I learned in undergraduate work are astounding. Even though the last post was discouraging to me, I haven't cried since then (luckily...knock on wood). The fact that I had one of the most difficulty staff relief positions was initially daunting, but now that it's completed I can say that I was shoved into the pool, and I learned how to swim (well, tread water well, anyway). 


As far as my staff relief, I'm down to the last two days and hopefully my BMT patient load will go from 2 patients to 1. I'm really hoping that one of our patients will be able to go home while I'm still here. She's been in the hospital for over a month now, battling gastrointestinal graft versus host disease (GVHD). She has a horrible history of chronic diarrhea (over 3 liters a day), cramping, and not being able to eat anything. We have her back on a pretty bland diet of crackers, rice, plain chicken, plain cereal, lactose-free milk, etc. Hopefully she can keep up the good work and get home! Plus, she invited me to her graduation/celebration-of-being-out-of-the-hospital party...I felt honored.


The general service is booming as usual, but nothing insanely outlandish that would be worth putting in the blog. Mostly just kids with fevers, urinary tract infections, rash, monitoring, etc. The kids on that service just blaze in and out faster than I can keep track. There may be a few consults here and there for nutrition-related things, but more along the lines of kids being picky eaters and/or having food allergies. 


So what's next for me after Friday? You'll have to wait for the next post to find out - as for now, time for bed! 

First time tears

Well, I made it 98% way through my internship without crying at work, but yesterday was a rough day and I just broke down. Staff relief is the most beneficial, yet grueling and challenging rotations. Especially when I have such huge shoes to fill and I don’t have the extensive experience under my belt. As I’ve said, I’m doing my staff relief in the pediatric bone marrow transplant position. The lady who normally covers this position went on vacation, so she’s not even in house for questions, as the case usually is during staff relief. So I’m truly doing this by myself.

The usual BMT RD is an amazing woman who knows pretty much everything about BMT and TPN: the medications, interactions, new therapies, what to do when this or that happens, when to start something, when to stop, how to teach, where to be, who to contact, etc., etc. She’s been doing the position for 10-20 years. I’ve been doing this position for two weeks. The second I got to work yesterday the phone rang, and it was another BMT team member.

We’re trying to cycle a patient’s TPN down so she can go on day passes, and hopefully eventually go home. The problem was, was that she was going to get an ECP treatment yesterday, that caused a 4-hour break in the middle of her TPN. From what I was told from the woman covering me, is that on days of ECP treatment, just run it as a 24-hour cycle and then resume normal TPN cycles the next day. So there was some debate about what to do, as we can’t just “make up” lost time by running a TPN faster. If you do this, it makes the dextrose enter the bloodstream too quickly, which can cause high blood sugars, or even collapsed veins.

It wasn’t really an issue, as I stated that I’d work on the issue and find a way that we could make everything work. What made me upset is that the staff member then asked the person who is signing my notes, and eventually called the lady I’m covering, who’s on vacation in California. I just felt as though 1) I wasn’t being taken seriously, 2) I was making huge mistakes, 3) that now my preceptors/other RD’s think I have no idea what’s going on, and 4) that my recommendations weren’t being trusted.

And for the first time in my internship, 9 ¾ months through…I cried at work.

But…I got through the day, I found a TPN schedule that would work and wouldn’t be a setback. My preceptor backed up my recommendations, and I got a morale boost from the MD. They reassured me that I’m doing fine. Today went better, as luckily the patient has no upcoming ECP treatments.

And…that I only have 7 days left. YES.

BMT, head pus, and modified goeckermans, OH MY!

Ugh. I'm getting SO close to being done! Today went much better than last Monday, and even had more to do than last week. I had 3 clinic patients, 2 BMT patients, and a handful of general pediatric patients. 

That's what I like about this position. I have a few patients who I see on a regular, daily basis. But then, I have a handful of patients that are on the general service and are in for a multitude of reasons such as dehydration, feeding problems, moderate injuries, or monitoring. There was a couple crazy admits this weekend, though. 

Such as...one of the patients was jumping on a trampoline with a friend when his friends teeth went through the back of his head. He went to an outside hospital to get staples in his head to patch it up. Well, the wound got infected and he was sitting at a race track over the weekend and the wound burst open and started pussing and bleeding everywhere. SICK! Needless to say he's here getting a strong antibiotic course and making sure that his head heals correctly.

Then, another patient was admitted for an intense skin treatment called a "modified goeckerman therapy" for severe eczema. It's for people who have chronic eczema or psoriasis. It's a week-long hospital treatment that involves the little boy being put in a spacesuit looking contraption. It pumps the suit full of moisture and chemicals that relax and soothe the skin. It will hopefully be a long-term solution for the skin. But this little boy has it worse - he has multiple food allergies including milk, soy, peanuts, and beef. But, he also doesn't like fruits, vegetables, orange-colored foods, or odd-shaped foods. Unfortunately for him, there's not much that I can do, especially since he's not being admitted for anything nutrition-related. But, I'm trying to help the parents find a multivitamin that's red colored (because that's the only color multivitamin he'll eat), and especially one that doesn't contain any of his allergens.

Did I mention that it's only Monday?

10 days!

Staff Relief Update

So, now the second post about staff relief! Turns out that yesterday and today went much more smoothly than Monday. I wasn't getting constant pages and I'm getting the hang of what I need to do and when I need to do it. Now with the small amount of extra time I have at the end of the day, I look toward the next day and figure out what will need to be done, who I'm going to see in clinic (what I might do pending how they're doing), and maybe even start my reassessment notes. 


My two BMT patients are doing well. One of the patients has a rather stubborn mother when it comes to tracking intake and providing supplementation and those sorts, and yesterday I had my first experience with standing my ground. She wanted to decrease the cycle time of TPN, in which would cost her daughter much needed calories and protein. I stood firm on that she'd go home on what I wanted her to, and put up a good fight. I still lost, but I didn't back down to what she wanted to do. She still wouldn't give in to ordering supplements, though I suppose I should just take it one triumph at a time.


In this position, I also cover one of the general pediatric services. There's not too many crazy conditions in this position, just more of kids who may be coming from the PICU, in for simple infections, or monitoring after surgery. Tomorrow I'll write more about some of the side conditions these kids have, which are very interesting...


I can't believe my first of three weeks is already halfway done, and I've survived! Tomorrow all the interns are having our pictures taken so there is a picture of us on our graduation program, as well as our director hangs the picture in her office. On Friday I have my end-of-the-year evaluation with the internship director, along with returning all of the books she provided us. After that, it's time to start studying for the RD exam, which I hope to pass in August.


What is really nice at this point is not having 5,204,183 projects and papers to work on when I get home. It's nice to just relax and do something for myself at the end of the day. 


15 days!

Staff Relief

I'm so overly excited that this is my final stretch. 3 weeks of staff relief. I was placed in one of the most challenging positions - pediatric bone marrow transplant (BMT). 


Let's just say that today was incredibly overwhelming. Definitely do-able, but overwhelming. It's like being at a new job and you know what needs to be done, but it all seems to come flooding in on the first day. Rounds got started late, 2 big patients came into clinic, 4 inpatients (2 incredibly needy ones), plus the pager never seemed to stop. 


What is nice is that I have no more big projects or papers to write. Thank goodness!! That is one thing that I'm glad to have a break from. 


So my day is as such...get to work at 7:15-7:30am, chart and catch up on patient labs and medications until 9am, when rounds are (supposed) to start. Then, rounds last until around noon-ish. After that I have to order the TPN for the patients for the next day, altering them as needed. Then, I complete any new assessments or reassessments for patients on the general service (which my position also covers). If there are any patients coming into clinic, I have to escape rounds/visiting patients/charting to visit them. All the while altering TPN prescriptions, tube feeding orders, and encouraging everyone to eat. Not to mention the 9,387,104 pages that I get and attend to. I usually work right up until 4pm, when it's time to go home. 


The nice thing is, is that I get to come home and do whatever I want. So today I went for a nice walk, painted my nails, and read my book. Things definitely even themselves out. I'm sure I'll have more to write later when I get the hang of things and settle into a routine.


But until then...


17 days left! 

Project Healthy Schools

Yesterday I spent pretty much the entire day driving around Ypsilanti Public Schools. It was SO incredibly hot, but very worthwhile.


Project Healthy Schools (PHS) is a health and wellness initiative for local Ann Arbor and Ypsilanti schools, aiming to improve their overall outlook on healthy diet and exercise. Yesterday started off by visiting Ypsilanti Middle School, where we promoted asparagus. They had asparagus they had on the hot lunch line was baked with some salt and (lots) of pepper. It was pretty good! We also put the informational fliers that I made on the tables, as well as went around with samples for all students to try. It was really fun encouraging kids to try new foods. Some really liked it, some said it was ok, some hated it, and some wouldn't even look me in the eye. It was awesome being around kids and having them be interested in a new food, or at least being more aware of what it is.


After that, we went to a local high school to do a screening of a student. With PHS, there have been a handful of published studies on the program, and whether or not it makes a long term effect. This student had been exposed to PHS when he was in middle school and now MHealthy staff members are following him, every year completing a survey. The survey includes data such as height, weight, blood pressure, cholesterol, blood glucose, and a lifestyle questionnaire. They take his and thousands of other student's information and compare it to students who weren't involved in PHS, to see if it makes any difference.


After the high school, we stopped at an Ann Arbor elementary school to drop off informational booklets to a teacher who is getting more involved with the administrative side of PHS.


So, needless to say it was a very long day on that aspect. Not to mention it felt like 100 degrees outside.
So after PHS later in the evening, I attended a MHealthy Weight Management class for adults. The class I attended was all about rearranging self-talk from negative into positive, and how it can change the overall outcome. 


Today's weather is supposed to be even worse. But luckily I'm not doing much traveling and will be spending the morning with one-on-one MHealthy counseling. More on that later...


22 days until graduation.
25 days until my birthday.
26 days until I start my new job! 

MHealthy

MHealthy is a health and wellness promotional program for U of M staff members. This program also encompasses Project Healthy Schools, a health initiative for local schools to improve physical activity and diet choices.


My day started off by going to a staff meeting where they discussed a big health fair they're going to be doing in September and October of this year. They're going to be doing cooking demos, having lots of health stations, and raffles and prizes. After the meeting, I met with one of the coordinators for Project Healthy Schools (PHS) in which she told me about what's going to happen tomorrow. I'm going to be going to a local area school to talk with them, promote, and give samples of asparagus! I also created a handout for tomorrow which gave fun facts and recipes for asparagus, and even a word search.


For the second half of the day, I went to a PHS site to figure out logistics of a field day that MHealthy is helping to put on. It was interesting to go to the schools and see the locations that MHealthy is working at and trying to help kids build healthy diet and lifestyle habits. 


Overall, I'm just ready to head back to the hospital. 


24 days.

Not so much.

I'm ready for this week to be over.


Yesterday I worked with another RD who does general nutrition counseling as well as works in the ALS clinic. This was definitely an interesting population with varying degrees of illness. We had some patients who you'd never know they had a degenerative disease that is eventually fatal, while others were no longer verbal, on ventilators, and completely dependent on others. The RD's role in this population is to make sure they don't lose weight, especially when their intake starts to decrease. This would happen because they lose motor neurons in their throat and lose the ability to coordinate a swallow. The patients, while they may be slightly overweight, are encouraged to have high calorie and protein intake. In doing so, it will preserve their muscle and prevent excessive weight loss.


Otherwise, today I was with the ketogenic diet RD. Again, we had no patients. It's definitely frustrating as I've just (literally) sat at the computer for 8 hours today and played around on a ketogenic diet calculator. Definitely frustrating. It doesn't help that I got my written case study back today and the RD who graded it was rather harsh. Guh. 


But, tomorrow I'm with the general nutrition counseling RD and it seems as though we have a wide variety of patients to see. One is an extremely obese pregnant woman and another is a man who has had bullet fragments in his abdomen for the past 10 years and is having some GI issues, which may or may not be related?


28 days. Please hurry up.