Internship: Graduation!!

It's been a long year, but fast too. We all survived the craziness of having Eliza in daycare and having me away for some long work days mixed in with Brian's travel schedule. It's good to have the year over, but it's also bittersweet to leave the great friends that I've made among my fellow interns and the nutrition staff at the hospital.

The graduation celebrations started with a staff luncheon at The Wine Market in Baltimore on June 24th.  The food was delicious and it was great to get everyone together to talk and have fun before our formal ceremony. The interns surprised the staff with a little book of drink recipes titled "RD Mixology" to thank them for sharing their expertise with us. I was in charge of all of the non-alcoholic contributions to the book. :) The staff loved their gift!

Today we had our formal ceremony at Davidge Hall at the Medical Center.  Davidge Hall is the oldest medical teaching facility in the northern hemisphere still in use so it was pretty cool to go there for our graduation.  The ceremony was nice and it was fun to celebrate the end of our year with our family, friends and the staff.  The director of perioperative services from UMMC (our director's boss) spoke along with our director, Ellen.  

When our diplomas were presented they said a little bit about each intern along with 3 defining words from the staff.  My 3 words were intelligent, inquisitive, and caring.  In addition to our diplomas we each received some very nice gifts from the staff.  After the ceremony we enjoyed a delicious cake from a French bakery in Baltimore, Patisserie Poupon, filled with cream and strawberries and topped with marzipan decorations - it was awesome!  We also had fruit, chocolates and lemonade.  

Our director, Ellen, read this poem at graduation:

TO UMMC They Came

Caitlin of Syracuse

Jamie Kansas State

Amanda from U of M

And Elaine RIT

They all came to Maryland

Seeking their RD

They were told it would be hard

No sleep to be had

RDs were mean and nasty

It sounded really bad

Well, they came despite the warnings,

Their pictures now on desks,

Time to get down to business

And put them to the test.

Their first four weeks in clinical

A new world of patients, notes and rounds

Even watched a surgery

And didn’t hit the ground!

Learned to speak the language

Like EN, PN, TF,ARF, CVVH and more,

KCl, MG, IV CVC, acronyms galore.

Worked with the healthcare team

To create the perfect plan,

A few times, the docs did not agree

And they strongly took a stand.

Foodservice at St. Agnes

Worked with our good friend Paul,

Created a café theme meal

A+ for them all!

Nutrition Month, Farmer’s Market

Employees taught what to eat,

Never bored and on the move,

They were always on their feet.

At the end, the last big hurdle

A case study to the staff,

But as we knew, they’d tackle that

And move along their path!

It was a fast nine months

A job well done,

We wish you all the best.

Remember you, remember us

And please do pass that test!

One last picture for the memories...graduation also means that I am done with commuting everyday!  I can't tell you how relieved I am to not have to drive into Baltimore every day.  

Internship Rotation 16: Community, 3 Weeks

I just completed the final rotation for my internship which was in community nutrition. I rotated through various outpatient clinics and worked with multiple dietitians in a counseling setting. These are the clinics that I visited:

• Pediatric Gastrointestinal
• Celiac Disease
• Pediatric Growth and Nutrition
• Bariatric
• Early Renal Insufficiency

I also spent time with the VA research dietitians working on a weight loss research program with participants willing to follow the American Heart Association guidelines. Besides these clinics, I spent time working on seasonal recipe and grass-fed meat handout projects for the Greene Street Farmers Market and completing the online WIC modules.

Above: VA Hospital

Below: UMMC and the bridge that connects to the VA

This was a crazy rotation because I also presented my case study during this time and had to spend a lot of time outside of my work days getting the information put together.

Up Next: GRADUATION!!

Internship Joint Class Days 2009-10

We spent a few days out of the year in class days with all of the regional interns. This allowed us to meet interns and students from Virginia Tech University, University of Maryland Eastern Shore and College Park, National Institutes of Health, Johns Hopkins Bayview Medical Center, Sodexo, Aramark and Howard University.

Topics that we covered:

1. Public Policy
2. Information Technology for Dietitians
3. Federal Regulations in the Nutrition Field
4. Research Techniques
5. Nutrition for Critical Care
6. Long-term Nutrition
7. Community Nutrition
8. Pediatric Nutrition

We spent time at the Maryland Dietetic Association Annual Meeting and also visited places like the Children's National Medical Center, Food and Drug Administration, Food and Nutrition Information Center/NAL, Johns Hopkins Bayview Medical Center, National Institutes of Health, Hebrew Home long term care facility, and, of course, the University of Maryland Medical Center in the Shock Trauma Auditorium.

Internship: Case Study Presentation

As interns, we presented case studies throughout the year during certain rotations, but each presentation was relatively small. Mostly, we presented on patients we'd followed through 2-3 weeks and only to the unit preceptors. Now that we're at the end of the year, all of the interns had to present a case study patient to the entire clinical nutrition staff. We each chose a patient to follow clinically and research. The information collected from our clinical assessments and literature searches were put into presentations and we each got a turn to share our work in meetings. Today was my turn to share and it went well! I am happy to have the presentation over, but it was a great experience. I chose a pediatric patient and found that research was very difficult to find because the condition treated in my patient is not well studied due to the low incidence and the whole pediatric population aspect which is just not well researched. I am still very happy with how things turned out and enjoyed working with this particular patient. I actually had 4 other case study patient options but none of them worked out-2 just didn't have research to back up my presentation, 1 died prior to nutrition support being started and 1 patient had a condition that had been presented in the past on multiple occasions and I wanted to be different. Check out my presentation below:

Chylothorax Case Study

Some of the staff attending the presentation. It's a bad picture, I know, sorry.

Internship Rotation 15: Staff Relief-Pediatrics, 4 Weeks

Me with Faith and Sara-the two pediatric dietitians.

The staff relief rotation is our chance as interns to prove ourselves as clinicians in our area of choice. It is our final clinical rotation and although it was kind of bittersweet to finish my clinical time, I am very excited to be coming to the end of our program.

I wanted to get more experience and time in the pediatric units so I arranged to stay with the peds dietitians an additional month. During the 4 weeks there I was responsible for the medical nutrition therapy for the 10-bed pediatric intensive care unit, the pediatric intermediate care unit and the high-risk patients in the floor units (2 additional wings). I managed around 12-18 patients at a time. This was my typical day:

1. I started by opening our electronic charting program to track any movements of my patients between rooms and to do patient sign-offs to the dietetic technician who works with most low and moderate risk patients.
2. I would then scan through the new admits to the PICU and check out their admitting diagnoses to prioritize my order of assessing the patients. Many new admits require a full nutritional assessment which involves collecting data about their current medications, lab values, anthropometrics and percentile plots, diagnoses, past medical history, home diet, and current nutrition plan followed by an assessment about their level of malnutrition, weight status, any factors affecting their ability to meet their nutritional needs and any other pertinent information. Some patients only required screens to determine their risk level and ths was a much less involved process involving just a diagnosis, anthropometrics and percentile plots, and current nutrition provision. Screens are typically conducted by dietetic technicians in our hospital, but no techs work in ICUs so I did the screens for the ICU beds when it was warranted. Patients who received screens were typically quick in-and-out patients such as asthmatics, overdoses, accidental object ingestions, and other accidents like snakebites.
3. Once I had my list ready I attended morning rounds with the PICU team which consisted of discussing each patient in the ICU and IMC. I participated as the representative from clinical nutrition and provided input for the nutrition therapy for each high-risk patient. Not all patients are at-risk nutritionally, when I say high-risk I'm referring to patients who require nutrition support such as tube feeding or parenteral nutrition. Occasionally, patients who are eating by mouth are also at high risk such as one pediatric patient with a Crohn's disease flare causing severe pain in her mouth and throat. She wasn't eating anything and was eventually tube fed.
4. Throughout this time I would collect my data, write assessments and create plans for each patient from my list. My recommendations would either be discussed during rounds or with the patient's resident later in the day who would then update the orders on the patient to reflect my desired changes.
5. I would then go chart on patients outside of the ICU and IMC in the regular floor units. I only saw patients in these units if clinical nutrition was directly consulted or if the dietetic tech screened someone at high risk nutritionally. Consults would show up on the multi-patient task list whenever a tube feeding order was placed or when a patient's intake triage showed the patient to have a high-risk home feeding situation such as tube feeding or multiple allergies (when I say multiple, I mean it, we had patients in with 7-10 allergies sometimes and they were usually diagnosed by someone reputable).
6. Once patient care was done for the day I would spend some time researching conditions or working on projects. One project was to do a combination milk- and soy-allergy handout since that was a common allergy situation.

Some of the patients that I worked with this time:

• non-Hodgkins lymphoma patient who developed typhlitis, bowel abscess and perforation who was on complete bowel rest with TPN (with some trophic gut feeds prior to the perf)
• infant admitted for tetralogy of Fallot repair who developed a chylothorax post-op, TPN dependent, recommended for high-MCT oil trophic feeds on Enfaport formula when cleared for feeds through gut, patient also had a fluid restriction due to abdominal and chest wall edema which prevented the chest from being closed after surgery for a full week (this patient is my case study patient so I'll talk more about this situation in another post)
• hemorrhagic pancreatitis with post-ligament of Trietz NJ feeds on CVVD for nephrotic syndrome with focal segmental glomerular sclerosis
• multiple g-tube fed patients: this is probably the most common area for work in the pediatric unit since so many conditions can lead to the necessity of a g-tube. Once a g-tube is placed, children can be fed chronically through this tube and they're often readmitted for problems with accidental tube removal, tube placement, or complications with other aspects of their care such as their tracheostomies.

I am really grateful to have been able to spend another 4 weeks with the pediatric patients. I ended my clinical rotations with 8 total weeks in the pediatric units which is more than any internship I've heard of. This was the area where I had the most interest and really wanted to get as much exposure as possible. I'm glad that I was able to achieve that with my program. I enjoyed the complexity of the work in these units because of the types of diseases that are present in childhood in addition to the fact that we treat based on age and end up with all kinds of medical situations. It definitely keeps the day interesting to have to pull together information from oncology, neurology, cardiac, nephrology, trauma, gastrointestinal, and other areas to get through a day in the peds units.

Up Next: Community, 3 Weeks (Then...GRADUATION!!!)

Internship Rotation 14: NICU, 1 Week

I spent this past week working with the preemies in the NICU which is a 40-bed unit divided into practice by general medicine, surgical, very low birth weight (less than 1500 g/3.3 lb), extremely low birth weight (less than 1000 g/2.2 lb), contact precautions and satellite (transition nursery). Many babies had complications with renal function, intraventricular hemorrhages, bronchopulmonary dysplasia, necrotizing enterocolitis, hyperbilirubinemia, and other concerns. Due to their prematurity, many were not at the age where they were able to suck and swallow food like a term infant. So these babies were usually fed through feeding tubes through their mouth or nose. We also fed babies using parenteral nutrition through the veins. Some had grown enough to reach the point where they were able to feed from bottles or be breastfed. It was a whole different world working with such tiny patients since everything that goes into these babies is affected by fluid limits, shifts in electrolyte lab values, underlying conditions and complications that arise. It's a very math-intense world with calculations for everything from calories/kg and fluid ml/kg to glucose infusion rates from multiple drips, and calories provided by the various formula/breastmilk options for each baby (did you know that breastmilk can be fortified to be a higher kcal/oz fluid using human milk fortifier or neosure powder?).

I feel fortunate to have completed this rotation. I am nowhere near ready to work in a unit like this but the experience gained in even a week provided a lot more insight than I had before into this tiny world of nutrition. In addition to nutrition insight, I learned a little about being pregnant while I was in the unit. Here are a few lessons to share:

1. Never use cocaine while pregnant, not even "just a little bit". Your water will likely break and you will go into labor. Then guess what? Your toxicology screen, and that of your baby, will show positive for cocaine and you'll be referred to CPS before ever taking your baby home.
   
2. If you're on strict bedrest for placenta previa, don't go out and play softball, not even just to "throw the ball". Once again, you'll likely go into labor in a situation that can't be reversed since you require an emergency C-section thanks to the position of your placenta. No drugs are stopping this labor.
   
3. Get early prenatal care and manage your co-existing conditions!

Up Next: Staff Relief in the Pediatric Units, 4 Weeks

Internship Rotation 13: Pediatrics, 3 Weeks

During this rotation we worked in the Pediatric Intensive Care Unit, Pediatric Intermediate Care Unit and the main pediatric floors within the University of Maryland Medical Center. We saw patients from 4 days old to 18 years old (any baby who has been discharged from the hospital and needs to be readmitted is admitted to the PICU, never to the NICU since they've been exposed to outside germs at that point in time and could worsen the prognosis of babies in the NICU with any further exposure to those germs).

I've been looking forward to this rotation all year since pediatric nutrition has always been my main interest and is the area that drew me into the field in the first place. I really enjoyed working in these units and helping with the diverse situations that are present in this age range. We were able to work with patients who have rickets, Cushing's syndrome from prolonged steroid use in Juvenile Rheumatoid Arthritis, newly-diagnosed type 1 diabetics, diabetic ketoacidosis, meningitis, failure to thrive, pyloric stenosis, multiple birth defects (including Trisomy 18, a patient born without kidneys and on peritoneal dialysis, cerebral palsy and others), mitochondrial diseases, lysinuric protein intolerance, eosinophilic esophagitis, short gut syndrome and many other situations. Some of the most difficult patients that I've worked with to this point were those who were in the hospital for societal reasons such as neglect or abuse. I am glad that I was able to be there to help these children escape their sad home lives in any way that I could. Fortunately, in the cases of neglect I was able to make a substantial difference considering that nutrition was often one of the areas that needed the most attention.

The rotation helped further my desire to work more in this field and I'll be returning to the pediatric units to complete my staff relief assignment after my next rotation.

Amanda and I were able to find time to get out of the hospital one nice day and enjoy some hot dogs at one of the vendor stands. I don't normally eat hot dogs, but we'd both been wanting to get outside and eating hot dogs would fill that desire so we went for it. Now back to the rotation info...

Key tasks during this rotation:

• plotting children's stats on growth charts and determining if stunting, wasting, obesity, overweight, underweight and/or malnutrition were present, with corrections for appropriate gestational age in preemies
• calculating estimated nutrition needs, which varies a lot from the adult world since adults are typically estimated in the range of 20-35 kcal/kg depending on disease state, clinical status, age, etc. Children are estimated in the range of around 50-120 kcal/kg with the higher range being for younger children
• calculating necessary formula concentration and pump rate to meet the needs of formula- or tube-fed patients using appropriate formulas based on patient allergies, sensitivities, renal status, fluid balance, age, etc.
• calculating and manipulating TPN/PPN orders for parenteral patients
• anthropometric measurements on pediatric patients such as triceps skinfold, subscapular skinfold, mid-arm circumference, etc.

We also got to see Brian Roberts from the Orioles one of the days in the PICU while he was there visiting the patients, which was pretty cool. He was signing autographs and handing out shirts and other promotional items.

This doll is one of the freakiest dolls that I've ever seen. This display case sits right outside all of the elevators that access the peds floor. This floor is also the location of the intern office so I see this crazy doll every day. After 8 months, I still don't like her any more than I did the first time I saw her.

Up Next: NICU, 1 Week

Internship Rotation 12: Trauma, 2 Weeks

This has been my favorite rotation so far. I enjoyed the variety in work, the complexity of the injuries and the story behind each patient. The two weeks flew by! The Shock Trauma Center is part of the University of Maryland Medical Center but is technically a free-standing hospital despite the connection in hallways; it is the primary trauma care facility for Maryland and is a level one trauma center so we were exposed to the most severely injured and sickest patients from the state. This trauma center is also well-known for being the first in the world to treat shock. We spent our weeks working with gunshot wounds, stabbings, traumatic brain injuries, motor vehicle crashes, motorcycle crashes, multiple types of brain bleeds, struck pedestrians, falls, and necrotizing fasciitis (part of the soft tissue segment of the trauma department). We then had to deal with the situations that come with these injuries such as colostomies, paralysis, chronic intubation/trach, long-term feeding tube access, long-term parenteral nutrition, uncontrolled blood glucose values, altered mental status, sedation, lean body mass breakdown, amputations and more. Some stories from the week:

• One of the patients was brought in after a drive-by shooting, but happened to have a warrant out for their arrest so they became a patient and a prisoner in one day. When the family came for a visit and got turned away by the police officer standing guard, a verbal fight ensued where one of the relatives almost got arrested for refusing to obey the officer.
• I had multiple patients die during this rotation but somehow I had more exposure to the families this time so it was more difficult, especially since most of the patients had been healthy prior to their traumatic injury and their death occurred at a completely unexpected time.
• We got to work with quite a few "interesting" patients where mental status declines led to some odd behaviors involving nudity, yelling, and cussing. One patient that we discussed with the med team was in with suicidal and homicidal tendencies. The homicidal tendencies were directed at medical professionals - so glad that I didn't work with them.
• We frequently had patients who were part of the evening news the prior night.

Some experiences:

• We got to tour the Trauma Resuscitation Unit which is the emergency department of the trauma hospital. We saw a surgery being performed through some doors but couldn't really see anything in detail.
• We also toured the hyperbaric oxygen (HBO) chamber where patients with necrotizing fasciitis and other serious wounds go to help their wounds heal through concentrated oxygen to help increase blood oxygen content.
• The hospital has a helipad where 3 helicopters can land to bring in patients and we toured that area as well. It was common to hear helicopters landing throughout the day so long as weather allowed. The day we toured the weather was rainy so no helicopters were on the landing area. It's a good thing the internet has photos of everything for me to use!

Up Next: Spring Break, 1 Week then Pediatrics, 3 Weeks

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