Our Lady of Bellefonte Hospital: Medical Nutrition Therapy, Week 2-4

This last Friday, as I was filling out my time sheet, I had to stop for a second and ask one of the other dietitians if this was actually the end of my fourth week of my internship. I actually had to stop as I was filling it out to check with them and make sure I wasn’t being an idiot. These first four weeks have absolutely flown by.

During the first two weeks, I was basically shadowing along with the other dietitians and helping out with the charting notes. But these last two weeks I have been like a baby bird leaping from the nest – I was starting to go into rooms by myself, asking questions, and gathering information all on my own. I’m perfectly fine talking to people, but this interview-style of talking to people is new for me. I have to make sure I ask the appropriate questions for this particular patient. Not only do you have to ask the appropriate question, you have to make sure you speak loud enough and listen very intently or else you can miss something important for your notes. I also got to perform my first nutrition-focused physical exam.

DHN NFPE pic.jpg

One competency I did well on was designing, implementing, and evaluating a presentation to a target audience (CRDN 3.4). I was lucky enough to give two different presentations on incorporating a high-fiber diet and why getting enough fiber is important. The class was for the cardiac rehab patients. This was new for me as well; all the presentations I’ve given up to this point have been for a younger audience. I found myself having to be careful about my word selection to make sure I used words and phrases that appealed to their level of nutritional understanding. The response I received from my audience was positive overall, so this felt great.

During my fourth week, I was with the behavioral unit the entire time with one of the other dietitians. As I said in my last blog post, this is where the patients with psychiatric disorders usually end up. In short, these patients can be quite unpredictable and you have to treat them a little differently than patients within the other hospital units. Specifically, with how you negotiate with them. This was a competency I want to improve upon (CRDN 2.8) because I can do fine when I have to talk to patients who are predictable. But when working in behavioral, you need a certain toolkit of skills that are most appropriate when dealing with these types of patients.

To elaborate further and demonstrate something new that I learned, I’ll use a certain patient who had an opioid addiction as an example. I learned that opioid use can be linked with constipation. According to Schwarzer et al., “It is mainly caused by linkage of the opioid to the peripheral mu-receptors in the bowel and may increase as a result of certain concomitant circumstances, such as poor intake of fluids or electrolyte disorder.” This was important to know because the patient was also abusing laxatives, possibly bulimic, and severely malnourished. Clearly a very complex case and I think gaining more experience will allow me to handle these situations and this competency better in the future.

After these first four weeks, I am immensely more prepared than when I first entered into this rotation. I am learning at an extremely rapid pace and I have loved working with the other dietitians. Most importantly, I feel like I am making a difference and starting to contribute to the health of the patients. I can’t wait for the weeks ahead. 


References:

1. Schwarzer, A., Nauck, F. & Klaschik, E. Schmerz. Strong opioids and constipation. (2005) 19: 214. https://doi.org/10.1007/s00482-004-0325-3

Our Lady of Bellefonte Hospital, Medical Nutrition Therapy: Week 1-2

Before the internship started, the rotation that I was most worried about was this one – my medical nutrition therapy rotation.

I was most concerned about this rotation because it is probably my biggest weakness when it comes to my gaps in knowledge and I feel as though the stakes are the highest. My mind went to the worst; I was going to hurt somebody by giving them the wrong tube feeding or I was going to look like an idiot in front of the others because I didn’t understand what certain labs or disease states represented.

After the first two weeks have come to an end, I can happily say that this was not even close to the reality. I have an amazing preceptor and the rest of the dietitians on staff have been more than welcoming. Oh, and I’ve learned a TON already just by paying close attention to how the other dietitians work.

The first activity they put me through was my training on the Epic computer charting system. I didn’t have this training for the first couple days as I was shadowing my preceptor and as she was explaining through the system I thought that I was never going to figure it out. She was puzzling this together with that and this told us this thing so we had to do something else…it was overwhelming. But after I got the training and started sifting through the program myself, the process started to become more and more natural. I’ve now began to chart and make notes on patients all by myself and it is a refreshing feeling. [CRDN 3.1 Perform the Nutrition Care Process and use standardized nutrition language for individuals, groups and populations of differing ages and health status, in a variety of settings.]

The second activity they put me through was my experience with the Behavioral Unit in the hospital. If you’re unfamiliar with Behavioral Unit’s in hospitals, they are the unit’s that deal with psychiatric patients and emotional and behavioral disorders. To say the least, it is a very different experience than working with patients on a regular hospital floor. You get a wide variety of patients and a wide variety of temperaments. There was an older lady there who was the sweetest little 96 year old I’ve ever met and there was another younger guy there who had a long history of substance abuse. The old lady called me handsome and the younger guy accused me of being a cop and said “I looked familiar.” So, like I said, this was an interesting experience, but fun.

Finally, the last activity and the activity that hit the closest to home with me was my experience in the Intensive Care Unit. If there is one thing that has stood out to me more than anything else during my first two weeks here, it is the perspective I have gained on the preciousness of life. The disease, pain, illness, and hardship that these patients and their families go through rocks me at my very core. It is the main reason why I have avoided the medical nutrition therapy side of dietetics. I can’t stand to see people suffer, but it is a necessary reality for so many of these patients and I’ve had to push out of my comfort zone a little to accept this. It gives me a higher appreciation for the doctors, nurses, dietitians, and everyone else on the supporting staff.

After spending a couple days in the ICU, there was an interesting topic that came up amongst myself and the other dietitians. It was about advanced directives and dementia patients and the ethics behind it. I basically learned about how having dementia can cause a person’s body to reject food. So, there are many cases when patient’s families have to discuss with the doctors about how they wish to proceed because they have to choose to feed the sick patient and cause them harm, or to refuse giving them any more food/liquids by mouth to aid-in-dying. I decided to look up the literature on this subject and found a great study that stated “One option for ensuring that one does not live years in severe dementia is to use advance directives to withhold food and water by mouth. The driving element behind VSED is that forcing people to ingest food is as objectionable an intrusion on bodily integrity, privacy, and liberty as imposing unwanted medical treatment.” (Menzel and Chandler-Cramer, 2014). This just showed me how tricky some situations can be and how important it is to talk with family before something like this could ever occur.

Overall, my first two weeks have been a crash course on how things work in the hospital. How teamwork, knowledge, and empathy for patients can all be combined to save people every single day, one person at a time.


References:

1. Menzel, P. T. and Chandler-Cramer, M. C. (2014), Advance Directives, Dementia, and Withholding Food and Water by Mouth. Hastings Center Report, 44: 23–37. doi:10.1002/hast.313

Orientation Week

Ahhh, the first week of orientation for our 2018 dietetic internship has ended, which means that our own personal chaos is about to begin.

I use the word “chaos” because we are essentially stepping into a part of our lives that is unknown. None of us have done this before and it is (hopefully) going to force us to produce “order” out of this chaos once we succeed.

We are about to take on one of the most difficult tasks of our professional lives. One that will bring us a step closer to our ultimate goal – the actual internship that will allow us to become a Registered Dietitian.

And in order to prepare ourselves for what is to come, this orientation was absolutely necessary, in my opinion. It served many purposes and allowed us to partake in several activities that should make the transition into our internship a little easier.

One of those activities included our discussion of The Energy Bus, which was a self-help book on becoming more positive and why it is a good idea to carry this into our respective internships. If this book had the capabilities of spewing sunshine and rainbows from it’s pages, I would not be surprised. This is not to take-away from the lessons of this book and I thought that it was actually an extremely fun read that allowed us all to come together and elaborate on the principles within.

This discussion forced me to see the internship in two ways: in a way where I put in minimal effort, begrudged every second, and did just enough to get by, OR in a way where I tried to enjoy what I was going through and as a result get stronger as an individual. I have to do the internship either way, and the latter of those two seems much more promising to my happiness. Luckily, I feel I’m already more of a positive and optimistic person in general, so this was a competency I felt I did well on. [CRDN 2.12 Perform self-assessment and develop goals for self-improvement throughout the program.]

The next activity included something new to me: the nutrition focused physical assessment. This was exciting to learn about because it provided us another tool in our professional toolbox to aid in the overall goal of a more accurate nutrition assessment to better help our patients. It was also introduced on the first day of class, so it was an…interesting…way to take a “hands-on” approach to meeting our fellow peers. I was completely unaware of the physical assessment, so due to my lacking knowledge I believe this is a competency I need to work on in the future.

The third activity that really stuck out to me was during the last day as we learned about the Code of Ethics as an RD. When I first received the packet, I didn’t think much of it because I already considered myself a person of integrity and a person who would always do the right, “ethical”, thing during my practice. After Mrs. Combs went over different scenarios where we had to discuss as a group whether or not the person was being ethical, I had to take a step back. I realized there were certain grey areas where the answer is not so cut-and-dry. It was an eye-opening experience.

Finally, the last activity I enjoyed had to do with an area I am familiar with, but not anywhere near an expert – research, with Dr. Plasencia (who was WONDERFUL, for the record). Most of the time when I think of research, I think of using objective data; facts, numbers, statistics, graphs, etc. But Dr. Plasencia assigned my group a research study that went against the grain and measured more subjective data. Specifically, human responses and words from each individual that took part in the study. This was necessary due to the main objective of the study which was to assess the learning experience after students were immersed into case-based learning for nutrition courses (Harman et. al, 2014). To quote the study, “Case-based learning has been widely used in law, business, medicine, and science education, but has only recently gained popularity in the health sciences field.”

What they found is that it worked. It worked because case studies prepare students for the multi-faceted problems they (we) will face in professional practice. I thought that this was a uniquely interesting study that expanded my knowledge on the current body of evidence.

Overall, I believe the orientation was a complete success. It was overwhelming, for sure, but I believe it will aid me and my fellow peers as we trek off into the unknown of this dietetic internship. Out of all the activities and lessons we learned throughout the initial orientation and as I come to a close with this first blog post, one thing I DO know about what is to come – it will all be worth it.

This pic just about sums up the week. :)

This pic just about sums up the week. :)


References:

1. Harman, T., et. al. (2014). Case-Based Learning Facilities Critical Thinking in Undergraduate Nutrition Education: Students Describe the Big Picture. J Acad Nutr Diet. 2212-2672.