Me with Faith and Sara-the two pediatric dietitians.
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:
- 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.
- 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.
- 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.
- 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.
- 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).
- 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.
- 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!!!)
