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