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
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?). 
