Internship Rotation 11: Surgical GI, 3 Weeks

Wow, what a rotation! Honestly, I've been a little anxious about this rotation all year. The preceptor is a very well-respected staff member among the clinical nutrition team and throughout the hospital. She covers the Surgical Intensive Care Unit and works with some of the most critically ill patients in the hospital. We spent the majority of our time in the SICU seeing patients as well but did work on a few patients in outside units. This was the first rotation where we worked with patients who required TPN for nutrition support (also explained in one of my January rotations here). This rotation wore me out with a 7:30 am rounds start time in the unit, but I really learned a lot and enjoyed my time working with the preceptor.

Some of the patients we saw: necrotizing pancreatitis, surgical cancer patients, liver transplants, gastrointestinal surgical patients (like colostomies, ileostomies, colectomies, gastrectomies, Nissen fundoplications, esophogectomies, paraesophogeal hernia repairs, and others), ulcerative colitis, intestinal and esophogeal perforations, etc.

Similar to the Medical ICU where I did my enteral rotation, the Surgical ICU is a unit where some of the sickest patients are treated. It was not uncommon to have patients code on a regular basis and to have patients in the unit die, including two of my patients.

Some learning experiences from the rotation:

- Post-op GI patients have a return of bowel function in the following order: small bowel, gastric, then large bowel. To determine when we should start feeding a patient again after surgery we check for bowel sounds, suctioned gastric contents (most patients come out of the OR with a tube from their nose to their stomach just for the purpose of suctioning the secretions back out of their stomach until function returns), then the passing of flatus or stool production.

-Patients can develop an ileus after surgery where portions of their bowel dilate and don't function for an extended period of time.

Quick overview of a paraesophageal hernia:

Paraesophogeal hernia: image showing the stomach herniated through the hiatal covering and sitting next to the esophagus. The stomach is not the only organ that can push up through a hernia opening, intestines and other organs can pop through too. A major issue occurs with a volvulus, or twisting, of the contents in the hernia leading the necrosis of the tissue. One of my patients had this issue and ended up with a gastrectomy, hemicolectomy and partial esophagectomy (so no stomach, part of his intestines removed and part of his esophagus removed). In patients like this the intestines can be directly connected to the esophagus for continued oral feeding.

Up Next: Trauma, 2 Weeks then SPRING BREAK IN COSTA RICA!! I can't wait!

Internship Rotation 10: Oncology, 2 Weeks

We spent this rotation with 4 preceptors so it was a little crazy getting back and forth for patient visits and note co-signing (we sign all of our assessment notes and then the preceptors co-sign before they get put in the medical record). One of the preceptors does only outpatient work so we spent time with her visiting the radiation oncology clinic and meeting with patients who were in for follow-up exams or radiation appointments. One of the preceptors is over the ENT and oral surgery in-patients so we saw cancers of the head and neck with her and the other two cover the in-patient cancer unit where most other cancers are treated. A few things I learned in this rotation:

• Certain cancer treatments can actually be related to the development of other cancers. One of my patients was in remission from breast cancer but then developed leukemia and the thought was that it was related to her chemotherapy for the breast cancer.
• Radiation treatments are like repeated severe sunburns in the same spot for the duration of the treatment (which is typically several weeks or more). The radiation machines are in lead-walled rooms with thick lead doors. The patients are the only people in the room when the machines are running. The systems are so technically advanced that they adjust to the patient's breathing to keep the radiation beam calibrated exactly on the site for treatment.
• Stem cell transplants are now performed instead of bone marrow transplants. Similar cells are transplanted but the techniques are different. Instead of the painful hip donation site portrayed in TV shows or movies, the cells are drawn out in more of an IV type device. The cells can either come from the patient themselves (autologous) or from a matched donor (allogeneic).
• Those who undergo stem cell transplants from a matched donor develop sort of a dual immune system so that two immune systems are fighting off the bad cells. Unfortunately, the donor cells can also fight against the native cells and lead to graft vs. host disease which can be fatal.
• When certain chemotherapy drugs are administered in patient rooms, radiation monitors must be used to check the levels of radioactivity and the rooms are completely covered to keep the chemicals off the floor and furniture. There are large black barrels to hold all waste from the room to ensure that there is no outside contamination.

Types of patients I saw in this rotation: stem cell transplants, breast cancer, leukemia, neck/tonsil cancer, pancreatic cancer, and cancer patients in remission being treated for other illnesses such as infections, and surgical scar resections. As for nutrition therapies for these patients, I worked with intermittent, nocturnal, and continuous tube feedings as well as oral diets. On a side note-this is the first rotation where I actually worked with a prisoner. There were always police guards in the room with the patient and the patient was handcuffed to the bed. I never felt unsafe but it was an interesting situation.

As you may know, my own mother is a breast cancer survivor who underwent chemotherapy and radiation treatments. I was asked by one of the preceptors if this rotation was more difficult for me since I had a personal experience with cancer. I answered that I didn't feel that it was more difficult because my mom had a positive outcome. She's been in remission for a few years now and she tolerated her treatments fairly well. I felt like the rotation was fulfilling because I got to make a difference in helping someone else's family member to have a positive outcome.

Up Next: Surgical GI, 3 Weeks

Internship Rotation 9: Enteral Nutrition, 4 Weeks

Enteral nutrition refers to nutrition provided through tube feedings. We spent this rotation in the medical intensive care unit (MICU) and the neuro ICU. We worked with patients who could be fed orally still but put most of our focus on patients who needed to be fed through a tube. Tubes can be put through the mouth, nose, or abdominal wall into the stomach or small intestines.

NOTE: This is NOT a picture of a patient from our hospital; it is a picture that I found on the internet. The red arrow is pointing to a nasally-placed feeding tube.

Some experiences from this rotation:

• We watched the placement of a nasojejunal feeding tube for a patient with severe acute pancreatitis. This means that the feeding tube was passed through the patient's nose, through his stomach and into the jejunal portion of his small intestine. Unfortunately, the placement didn't go too well because the patient wasn't very happy to be having a tube crammed down his throat while he was nauseated. Once the placement was done, they did an x-ray (which they always do to make sure we're feeding into the right portion of the digestive tract and not into the lungs) and found that the tube had gotten stuck in his stomach. So, they took it back out and didn't feed the patient (it's not advisable to feed a patient with pancreatitis prior to their small intestine because earlier feeding in the GI tract will lead to pancreatic stimulation. In the case of pancreatitis, the production of more enzymes leads to pancreas autodigestion and breakdown so the patient could potentially lose their pancreas and develop type 1 diabetes).
• We also saw patients who needed Blakemore tubes to stop bleeding in their esophagus. Blakemore tubes are balloons that blow up inside the esophagus to put pressure on bleeding areas similar to compressing a cut to stop bleeding externally.
• We spent some time with a respiratory therapist who showed us all of the options for ventilation. Many of our patients were intubated so learning about the machines attached to them was important for us to use in assessing the clinical status of our patients. We saw patients on ventilators, oscillators, ECMO and other respiratory machines.
• Unfortunately, the unit where we worked this time held many of the sickest patients in the entire hospital. It was not uncommon to have a patient die most days of the week that we were in the unit (including at least two of my patients).
• Types of patients we saw in this rotation: stroke, suicide attempts, alcohol withdrawal, brain damage, seizure, respiratory failure/distress, end stage COPD, pneumonia, trigeminal neuralgia, intracranial hemorrhages (many that had occurred while shoveling snow), pseudo-aneurysm, septic shock, bacteremia, and fungemia. Many patients were intubated and sedated (with propofol, which provides 1.1 calories per mL, some patients were receiving over 1000 calories per day just from their sedation).
• We used many types of feeding formulas such as Jevity 1.2 (the numbers refer to the amount of calories per mL), Osmolite 1.5, Glucerna 1.5, Nepro with Carb Steady, and Oxepa.
  

Up Next: Oncology, 2 Weeks

Internship Rotation 8: Clinical Management, 1 Week

We spent this week shadowing our internship director who also happens to be the director of clinical nutrition at the hospital. We attended a lot of meetings, and spent time discussing management issues such as discipline, hiring/staffing, and information dissemination. We spent part of our time completing audits of RD and dietetic tech medical record documentation concerning timing and assessment. We also did some research to prepare for the creation of a new clinical nutrition web page for the hospital and spent time taking photos of the staff to use on the new site. The week provided great insight into how the clinical nutrition side of the hospital overlaps with nursing, hospital management, foodservice and other areas of the full facility operation. While attending the manager's meeting we learned that the hospital was canceling their foodservice contract with a big name contract company in order to go to a self-operation, which is a big deal in the world of large scale food operations. We also got to learn how the hospital is getting involved with the Haitian earthquake relief - they're sending rotating teams of physicians and nurses led by the Shock Trauma department (did you know that UMMC is the home of the first Shock Trauma in the nation?).

Up Next: Enteral Nutrition, 4 weeks

Internship Rotation 7: Nutrition Support, 1 Week

I spent this week learning how to work with patients who need parenteral nutrition, which is nutrition support provided through the veins. Patients receive their nutrients through a fluid containing amino acids for protein and dextrose for carbohydrates plus electrolytes, vitamins and minerals. The fat can also be a part of this formula or it can be administered separately. Our hospital uses a 2-in-1 system where patients receive the amino acid/dextrose portion in one bag and the fats in another bag. Certain medications can also be added to the solution. This type of nutrition is used when a patient does not have a working gastrointestinal tract so they can not be fed orally or through a feeding tube. Parenteral nutrition is typically provided through a central line (such as a PICC or a subclavian line, called Total Parenteral Nutrition/TPN), but can also be provided through peripheral lines if the solution is dilute enough. This type of nutrition is a bit risky because it is associated with liver damage, metabolic bone disease and line sepsis if the patient gets a line infection, but it is often the only option to feed certain patients so these risks are just part of the deal. Patients with short gut syndrome, distal intestinal fistulas or an ileus (look these up if you want to know what they are, just know that the pictures can be quite graphic), severe pancreatitis, and inhibited ability to get adequate intake through oral or tube feed route over 5-7 days, and intractable nausea and vomiting (such as with hyperemesis gravidarum in pregnant women) can all be treated with parental nutrition. People can be fed on this type of nutrition for a few weeks to many years. We will be learning more about this area of nutrition throughout the rest of our year. This week was just a classroom overview to get us ready to deal with these complex patients.

During this rotation we got to go to a home infusion company's site to watch a TPN being compounded. We had to go into a little room, put on hair bonnets, face masks, full length lab gowns, and sterile gloves before we could go into the compounding room. The company mixes chemotherapy, IV meds and TPNs in the room but we just watched the TPN. The machine below shows all of the separate components hanging and waiting to be mixed into one bag by the machine. The white bag on the right is the fat solution and the other bags are probably amino acids, dextrose, electrolytes, meds, and maybe the micronutrient (vitamins and minerals) additive. I borrowed the picture from the internet since we weren't actually allowed to take any pictures in the room.

This week was also my first exposure to the Shock Trauma Center at UMMS. It was quite the experience since the patients in this part of the hospital are typically admitted for traumatic injuries such as motor vehicle accidents, gunshot or stab wounds, falls or other serious bodily damage. I'll get into this more when I actually work my trauma rotation in a few more months.

Up Next: Clinical Management, 1 Week