Internship Rotation 6: Liver Transplant & GI, 1 Week

I just completed my liver transplant and GI rotation which was a week long. It was a quick week but really busy. I saw patients who had already been transplanted and patients who were still waiting for a transplant. The best part of the week was finding out that one of the patients had just made the liver transplant list which is quite an involved process. Some common features of the week were jaundice, ascites and encephalopathy. During this rotation we had to use our best judgement to determine a patient's "dry weight" in relation to liver disease because ascites add quite a bit of weight to a person's frame without adding nutrient needs.

This week was also the hospital-wide holiday party which was huge! There was an entire corridor in the hospital that was closed off to patients and visitors where the employees entered and were treated to a free buffet of hot and cold hors d'oeuvres, drinks and desserts. The party area was set up with tons of decorations and lights and it was really nice. We also had our department holiday party earlier in the day so I ended up with lots of yummy food by the time I left. Plus I won some Kitchenaid mixing bowls and some cutting boards in the gift exchange.

Up Next: 2 Weeks of Winter Break!! Then: Nutrition Support, 1 Week

Internship Rotation 5: Renal Transplant, 2 Weeks

We started out this rotation a few weeks ago by attending a dinner/lecture meeting sponsored by Amgen at Morton's Steakhouse in Baltimore. We had an awesome meal followed by delicious cheesecake while we learned about dialysis outcomes for patients in renal failure. It was an interesting presentation, but the free food was what really made the night. Other than the free meal night, the rotation ran pretty similarly to our previous clinical rotations except that we worked in inpatient and outpatient settings concurrently. We dealt with newly-transplanted kidney patients, rejection of previous transplants, and patients with transplants who had symptoms come up that could cause serious complications due to the long-term immunosuppression meds used to prevent rejection. We also saw pancreas transplant patients in this rotation since many patients get simultaneous pancreas kidney (SPK) transplants. We saw all types of kidney transplants: living related, living unrelated, and cadaveric.

Up Next: Liver Transplant, 1 Week

Internship Rotation 4: HIV, 4 Days

We spent this rotation seeing patients all over the hospital who have a diagnosis of HIV/AIDS. We'd start some mornings by attending rounds where we'd learn about all patients within a specific unit. Then we'd receive our patient assignments and head out to find them and make our assessments. This was a really interesting rotation because of the complexity of the disease state involved with HIV. Some patients were well-controlled and compliant with their medication regimens and others didn't put in as much effort (whether due to their own choices or lack of resources). It was common to have patients who were "frequent flyers" at the hospital who would check out of the hospital against medical advice and then return a few days later with some other complication and typically test positive for a multitude of illicit drugs. We saw patients with many opportunistic infections commonly associated with HIV/AIDS such as Kaposi's sarcoma, pneumocystitis pneumonia (PCP or PJP pneumonia), candidiasis, and herpes.

We learned a lot about the different levels of precaution in the hospital in this rotation. Due to the nature of certain infections or the risk of influenza, some patients had full airborne precautions where we would have to enter the room in full suits with head hoods, face masks, gowns and gloves (I skipped this and just called these patients on the phone) or droplet precautions that required eye covers and mouth/nose masks in addition to gowns and gloves or just contact precations where we have to wear gowns and gloves.

Up Next: Renal Transplant, 2 Weeks

Internship Rotation 3: Diabetes, 3 Days

A little trivia for you (answers are at the bottom):

T/F Eating too much sugar causes diabetes.
T/F Type 1 diabetes is only diagnosed in children and Type 2 refers to a diagnosis of diabetes as an adult.
T/F Being diabetic means that you can not eat any sugar.

T/F A common diabetic medication can also be used in infertility treatments.

This rotation was completed by spending three days at the Joslin Diabetes Center, an outpatient diabetes clinic housed in the University of Maryland main hospital. While there, I sat in on patient nutrition counseling sessions and visited patient classes covering topics from nutrition to medications. During this rotation I carried around a glucometer and checked my blood sugar multiple times a day to get an idea of how diabetics have to manage this as part of their regular routines. It was an interesting experience and it also confirmed that I do NOT have diabetes since my levels were well below the diagnostic values. My intern partner did a practice injection as well, but I skipped this since I've already done a few subcutaneous ab injections with infertility meds. I had to complete a project for the clinic so I chose to make recipe handouts with the recipe cost, nutrition information, and serving suggestions. The assignment was easy since I was able to use some work that I'd already completed in the past with just some formatting changes. During the rotation I was also able to attend a couple of "lunch and learn" sessions to learn about new diabetic products and treatment protocols. It was really interesting to learn about continuous glucose monitoring where a patient wears a sensor inserted just under their skin in their abdomen and the sensor continually checks the blood sugar levels of the patient with the ability to set off an alarm when the values get too high or too low. How cool is that! It's an awesome technology but super expensive because the sensors have to be replaced every couple of days. I also got to learn about insulin pumps, insulin types, pen injectors vs. syringes and many other things. It was a very informative rotation.

Some class materials: beverage options (some recommended, some not) and some sugar tubes. The tubes show sugar amounts in some common foods. The tubes represent (L-R): 2 T. pancake syrup, 1 3" chocolate chip cookie, 12 oz. regular soda, 1 3 oz. brownie and 1 cup regular ice cream.

Answers:

1-False. Eating too much sugar DOES NOT cause diabetes. Rather, the disease is related to the body's inability to produce insulin due to damage to the beta cells in the pancreas (type 1) or the body's inefficient use of the insulin that is produced (type 2-although the two types are really more complicated than this).

2-False. Type 1 is typically diagnosed in children, but not always and type 2 used to be an adult-associated disease, but has now become prevalent among children with the rise in overweight and obesity. The types used to be called juvenile or adult-onset but these terms are no longer used since the distinction is no longer clear. Also, type 1 may be referred to as insulin dependent diabetes because all type 1 diabetics must use insulin, but type 2 diabetics may also require insulin so insulin-dependent and non-insulin dependent diabetes are also outdated terms.

3-False. Diabetics can still eat sugar. Type 1 diabetics use insulin injections to cover their sugar (or any carbohydrate) consumption. The more they eat, the more insulin they need. Type 2 diabetics typically have a limited amount of carbs as part of their eating plan and their body processes them with help from oral medications and lifestyle adjustments. Like I said above, some type 2 also take insulin to help with carbohydrate breakdown.

4-True. Metformin (glucophage) is a common diabetic medication that helps with insulin resistance. The medication may also be used in women with polycystic ovarian syndrome to help with conception since women with PCOS have issues with insulin resistance that affect ovulation. This medication is how we were able to have Eliza.

Up Next: HIV, 4 days

Internship Rotation 1: Cardiac, 3 Weeks

I finished my cardiac rotation in October, but I hadn't posted the rotation until now because I've been waiting to visit the OR still for an observation. I still haven't gone to the OR, but the nurse practitioner is working on arranging my time. Anyway, this rotation was 3 weeks long. I worked in two telemetry step-down units, the cardiac surgical ICU and one critical care unit. This was my first clinical rotation so I spent the first few days just getting accustomed to the surroundings of the units. At first, I was annoyed by all of the beeps and alarms in the hallways to signal to the nurses changes in heart rates or beat patterns, but I had tuned out the noise completely by the end.

I worked in this rotation with all three of the other interns. Clinical rotations require that we read the patient's medical charts (regular, bedside and electronic), compile all pertinent data (prior medical history, previous surgical history, current medical procedures, meds, labs, GI information and current diet orders), interview the patients concerning nutrition topics, assess the patient's nutritional risk and make plans for improving their status. Our plans for the patients include requesting lab orders, electrolyte repletions, changes to diet orders or supplement additions or suggesting possible medications to help with nutrition-related lab values, and other things. Once we come up with our suggestions, the information is discussed with the patient's care team and then the physicians or nurse practitioners place the actual orders. We write up an official progress note that is signed by us and our preceptor and then it becomes part of the patient's record. Pretty cool, huh?!

Patient types that we saw in this rotation:
Cardiac- post-op coronary artery bypass grafts, heart transplants, fistulas involving the cardiac organs, cardiomyopathy, hypertension, coronary artery disease, endocarditis, congestive heart failure, hyperlipidemia, other heart surgical patients
Other- lung transplants, diabetes (patients with diabetes will likely be in every rotation because it is such a wide spread issue), pancreatitis, gall stones, bowel ileuses, and malnutrition

Some highlights from the rotation:

• Watching a live surgery in the OR (Like I said, I haven't done this yet, but hopefully I will in the next couple of weeks now that I'm back at the main hospital).
  
• Watching an emergency surgery performed in the ICU to repair a bleed. We stood right outside the glass wall of the patient's ICU room and watched him get his chest cut open, get blood transfused, and get electrocautery done to stop bleeding. We didn't watch the full procedure because it took a few hours and the patient ended up in the OR (the surgery was started in the room because no ORs were available at that time).
  
• Meeting some really nice patients.
  
• My very first official progress note on day 1! Of course, I went on to write 20+ more by the end of the rotation, but that first one was a huge accomplishment and it felt great to sign the note and add it to the patient's record.
  
• Witnessing the value of good nutrition first hand.
  
• Bonding with the other interns while working through our frustrations together.
  
• Wearing my white lab coat for the first time.
  
• Getting to see continual dialysis, EKMO, and bypass machines in action.
• Watching the cool medicine carts that drive around the hospital automatically without human help. They can even get themselves on and off of elevators. The one that I've seen most is named "Harriet".
  

Some non-highlights from the rotation:

• Having one patient hand me his bloody tissue. Don't worry, I was fully gowned and gloved when he did it, but that didn't stop me from rushing to the bathroom to scrub down for about 5 minutes afterward and then using hand sanitizer every time I passed a bottle.
  
• Interviewing one patient while she was using the bathroom.
  
• The smell of electrocauterization.
  
• Getting sick with some virus in the middle of the rotation and having to stay home with a nasty fever. Then taking another day off at the end to accommodate Eliza having a fever.

Up Next: Foodservice, 5 Weeks (I already posted this one out of order a couple of weeks ago)

Internship Rotation 2: Food Service, 5 Weeks

This rotation was completed at St. Agnes Hospital in Baltimore and lasted five weeks. Food service is my least favorite area of dietetics, but the rotation was actually quite fun. To clarify, dietitians in food service don't work in food preparation; they typically fill management roles. I knew we weren't going to be assembling patient trays, but I didn't really know what to expect beyond that. My partner and I were assigned to re-write the cafeteria six-week cycle menu which involved planning a specialty entree, two meat entrees, one vegetarian entree, three or four sides and starches, grill items, and two soups which we added to their standard breakfast and salad options. These menus will be used for production when serving staff and guests of the hospital, but not patients. We built the menu using past sales data which led us to the most popular items: fried chicken, spaghetti with meat sauce, collard greens, macaroni and cheese and shrimp scampi with angel hair pasta. These were all put on the menu multiple times but most other items were used only once so we could keep a lot of variety available for repeat customers. We also had to factor in other dietary considerations such as providing a heart healthy option each day and we had to be careful of religious considerations as well so that we provided options for Halal and Kosher customers who don't eat pork or shellfish and for Catholic customers who don't eat meat on Fridays. In addition to writing the menu, we also calculated the nutrient analyses of the daily menus, and created menu signs with purchase prices.

We also had to plan and implement a single-use theme meal menu. We chose to do a "Fall Festival" meal and planned our menu to include: chicken marsala, roast beef with gravy, butternut squash risotto, rosemary roasted fall vegetables (sweet potatoes, red potatoes, carrots and parsnips), mashed potatoes, collard greens, corn bread, hot apple cider and warm apple, pear, cranberry crisp. The mashed potatoes were supposed to be egg noodles, but the staff changed them up at the last minute because of some miscommunications, but everything worked out well anyway. Amanda and I were responsible for finding recipes for any item not included in their standardized recipes so we created the fall vegetable, risotto and crisp recipes from family-sized recipes and scaled them to make 100 servings. Once the recipes were scaled, the cooks sampled the recipes at 25 servings and then we made adjustments based on our taste tests to finalize the recipe ingredient amounts. All of the recipes were successful and have been added to the St. Agnes menu rotations. We were also responsible for creating menu signs and pricing our menu which led us to create a combo meal option for the day. We charged $5.50 for one entree, two sides and a 16 oz. fountain drink which provided a decent profit for the facility while allowing the patrons to get a good deal as well.

Donna making our butternut squash risotto in a tilt skillet. The picture below shows our crisp which was made by Ms. Laura, an 82-year old retired St. Agnes foodservice worker who comes back 2-3 days a week as a volunteer to make the best desserts ever (she sent us out the door with samples of her bread pudding earlier today)! The picture also shows the sign advertising the apple cider which we gave away for free in another area of the cafeteria.

Other things that we did:

• Shadowed a clinical dietitian to see how their charting and assessments work.
• Visited patient rooms with the patient nutrition representatives to see how they presented the daily menu items verbally and took meal orders. This is something that I will never do as a dietitian but it helped give me an understanding of how everything worked with patient feeding.
  
• Sampled test trays from the patient tray line.
  
• Sampled food in the cafeteria for quality, taste, texture and temperature standards.
  
• Conducted storeroom inventory.
• Shadowed a foodservice management dietitian.
• Checked out the pressure fryer (think pressure cooker but full of hot oil, seems pretty dangerous to me, but they've built in plenty of safety features) used by every Chick-fil-A which leads to the chicken being in the fryer less time.
• Placed bulk food orders to their food distributors.
• Toured the SYSCO distribution facility.
• Calculated daily late tray requests.
  
• Had daily lectures over foodservice topics such as food preparation, budgeting/accounting, management, HACCP procedures and much more.

FYI: I listed this rotation as #2 even though you haven't seen a post about any other rotations. That is because I started with a cardiac rotation that was 4 weeks long, but only completed 3 weeks prior to the start of our foodservice rotation. My intern partner and I have to return to the main hospital next week to finish cardiac.

Internship: Orientation

I just completed the two-week orientation portion of my internship. During the two weeks I learned about standard things such as hospital policies and procedures, electronic charting using PowerChart, paper charting, diet order requests through CBORD, the layout of the hospital, HIPAA, patient interviewing skills and use of the university's library system among other things. I also spent some time touring the formulary room where a couple of people work doing nothing but mixing infant formulas in a sterile environment. Then I spent one morning sampling many of the dietary supplements (like Boost and Ensure), tube feeding products (like Jevity and Oxepa), and dysphagia diet thickened liquids given to patients so that I would understand why patients may complain about certain products. One morning I shadowed a dietetic technician (DTR) where we interviewed three patients. Then I also shadowed two registered dietitians (RD - what I am working toward becoming) for two separate mornings. One day I spent in the SICU (surgical ICU) and one other unit where we interviewed two patients and did rounds with the nurse practitioner and RN for the unit. The second RD works in the NICU so we spent our time there checking TPN orders (IV feedings) and rounding with the attending physician, unit nurse practitioners and the unit nurses.

The two weeks of orientation went by quickly! I really like the other three girls who matched at the program with me. One of the girls is from here and the other two moved here from upstate New York for the internship. We all get along really well and I think the year is going to be a lot of fun mixed with the copious amounts of work coming our way. I've been paired with the other girl from Maryland so we'll complete our rotations together for the remainder of the year while the two New York girls do their rotations together. We all have to complete 22 weeks of clinical rotations, 5 weeks of foodservice, 3 weeks of community and then 4 weeks of staff relief in an area of our choice. We also have "joint class days" throughout the year where we meet up with all of the dietetic interns in this region for lectures covering various topics.

Up Next: Cardiac Clinical Rotation, 2 weeks