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

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