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...