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...

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....