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!