Harrison Co. Public Schools, FSSM Rotation: Weeks 7-8

The last two weeks have been absolutely chaotic, but they have been worth it. The other interns and myself got the opportunity to attend Camp Hendon, which is a diabetes camp for mostly Type 1 diabetics. It is located in Leitchfield, KY and we stayed there for a full week. And when I say a full week, I mean we got in some solid 14-16 hour days. Type 1 diabetes, to my surprise, is actually on the rise over the past years and it is predicted to continue to rise all the way up to 2050, especially in minorities (Dabelea et al., 2014).

I was lucky enough to be placed in the camper group that I signed up for: the Eagles, which is the 16 and 17 year old campers. These made me want to tear my hair out multiple times while I was there, but overall, I really enjoyed being one of their camp counselors and I’d even go as far to say that I miss being around them. They decided to start calling my “Uncle Matt” because I was the one counselor who was slightly more lenient than the other campers, and they felt they could be themselves around me, which made me feel good because that’s all I wanted. I helped these kids out throughout camp, but they played a huge part in helping me out, too. Specifically, when they would all join together and start chanting my name to peer pressure me into doing things I didn’t necessarily want to do – take the midnight ziplining, for example. This made me “stretch” in multiple ways and I think I returned the favor many times over, so I think a competency I did well on was CRDN 2.3 Demonstrate active participation, teamwork, and contributions in group settings.

Another activity that I was really hesitant about doing was the 2 am rounds, where we checked the campers blood glucose levels in the middle of the night. We had to make sure they were above 120 mg/dL and if they weren’t we had to feed them a snack. As you can imagine, most of these campers were not too thrilled to be awakened so soon after falling asleep after an intense day. I felt bad I was waking them up, but I knew these were the rules and it was only for their well-being.

Finally, the last activity from camp was working in the kitchen to prepare meals. Each intern had to work one meal shift and one snack shift. When it was my turn, we were serving spaghetti to the camp. I thought this would be fairly simple, but since the campers are all required to carb count, it made the spaghetti quite a challenge to try and quickly fit noodles into a 1 cup serving size (or two ½ cups, in my case). Food allergies, portion sizes, special diets – there was nothing missing from making our staff work as hard as possible. Haha. However, one thing I thought was cool was the emphasis on discarding trash in the appropriate bins: either compost, trash, plastic, etc. There was a large effort in trying to discard of waste properly and I think that’s something I need to work more on so a competency I need to improve is CRDN 4.6 Propose and use procedures as appropriate to the practice setting to promote sustainability, reduce waste, and protect the environment.

Through the good and the bad, Camp Hendon is an experience I will never forget.

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References:

Dabelea D, Mayer-Davis EJ, Saydah S, et al. Prevalence of Type 1 and Type 2 Diabetes Among Children and Adolescents From 2001 to 2009. JAMA. 2014;311(17):1778–1786. doi:10.1001/jama.2014.3201

Harrison Co. Public Schools, Community Rotation: Week 5

Working at the Harrison County Public Schools has been a rewarding experience so far. These last two weeks have been slightly different than the first few weeks. I was asked to go speak at the Harrison County Career Fair; I have been working in the cafeteria with a few of the lunch ladies from the elementary schools; and I was able to conduct my plate waste study.

My preceptor and I have had the awesome opportunity of helping out with the Summer Foodservice Program for the Harrison County students. This is a program that provides breakfast and lunches to kids in more rural parts of the county who may have poor food security and less financial stability. Research by Gunderson and Ziliak (2014) showed that in 2012, nearly 16 million U.S. children, or over one in five, lived in households that were food-insecure, which the U.S. Department of Agriculture defines as “a household-level economic and social condition of limited access to food.” A typical day consists of me going to the middle school cafeteria and prepping the lunch for the day. These are usually sack lunches that include at least one serving of meat, dairy, fruit, veggie, and a whole grain. We normally prepare around 150 lunches, so we spend all morning prepping the food and getting it ready for delivery. I have now gained plenty of experience doing the same task over and over again, along with learning how to clean and prep the food as efficiently as possible. This requires a lot of teamwork and I think we have done really well so far, so a competency I did well on was CRDN 2.3 Demonstrate active participation, teamwork, and contributions in group settings.

 The next activity I got to take part in was the Harrison Co. Career Fair held at the high school. The organizer of the fair and my preceptor suggested I go and talk to the kids about how to obtain a career in dietetics. The audience was mostly sophomores and juniors and included about 17 kids. I explained to them the process of becoming a dietitian and the different job opportunities that were available to them if they decided to go that route. I also got the chance to demonstrate the wide variety of non-conventional career options that are rapidly becoming more available to them with the increasing popularity of the Internet. They seemed to be interested and it was well-received.

Finally, the last activity I did was conducting my plate waste study. Since I have been working on delivering lunches each day at the summer site, I thought this was a perfect opportunity to gather my data for the study. I decided to use milk as my main focus because it was much easier to gauge how much was wasted. I had each kid pour out their unfinished milk into a bucket which I later weighed. The kids seemed to actually enjoy pouring their milk in because they wanted to help contribute to my study. It was conducted at a summer site with about 50 kids available. Even though most of the kids love drinking all their milk, I did have a few participants to help me out. This was the first plate waste study I have ever conducted and it showed me I have a weakness in making sure the food we use is accounted for and waste is minimalized as much as possible. A competency I would like to improve on is CRDN 3.9 Coordinate procurement, production, distribution and promoting responsible use of resources.


References:

1. Gundersen, C. & Ziliak, J. P. (2014). Childhood Food Insecurity in the U.S.: Trends, Causes, and Policy Options. The Future of Children 24(2), 1-19. Princeton University. Retrieved June 25, 2018, from Project MUSE database.

Harrison Co. Public Schools: FSSM Rotation, Weeks 1-2

Things have been off to a great start at my new rotation at Harrison Co. Public Schools. I’m pretty confident that food service is the pillar of nutrition that I am most lacking, so I’ve been looking forward to expanding my skillset in the area. This is also the home stretch of the internship, which makes this rotation even more special. I have learned so much and I’m ready to apply the skills I have learned in the real world. But first, I’m going to make sure to give this rotation the attention that it deserves. So far, I’ve already completed a few activities worth sharing.

The first activity was helping the high school cafeteria workers with the preparation of the last lunch before school let out for summer. There was a lot to get done – prepping the sour gummy worms in small plastic cups; pouring and mixing the large amounts of mac n cheese; putting buns on all of the chicken patties; and then serving the children. It was a very nostalgic moment for me because I remembered eating those same chicken sandwiches every single day for my high school lunch and there I was, making them for other kids. J  I believe this is a competency I did well on: CRDN 2.4 Function as a member of interprofessional teams.

The next activity I did was sit-in on a counseling session between my preceptor and a parent of kid who attended school here. The kid has gastroparesis, which is characterized by delayed gastric emptying of fluids and/or solids without evidence of a mechanical gastric outlet obstruction. This made eating a typical school lunch extremely challenging and we were trying to figure out some options the kid could eat each day. I wanted to learn more about gastroparesis, so I found a great paper by Saliakellis and Fotoulaki (2013) that stated management of gastroparesis includes dietary and lifestyle recommendations such as small-volume and frequent meals with low content in fat and non-digestible fibers. Those with the condition are advised to avoid carbonated beverages and lying down for 1 to 2 h following meals. After some discussion with the parent and the lunch workers, I think we came to a beneficial solution for the future.

Finally, the last activity I got to experience was serving the staff members a meal after they completed their mock school shooting training. Lee’s Famous Chicken catered the entire event and we had TONS of food to serve to the faculty members. We organized 2 self-serving buffet style lines that allowed for the food to be served as quickly as possible. Everyone seemed to really enjoy the meal and a lot of them took home extra portions. This was highly encouraged because we had so much leftover food due to the high school faculty members that didn’t show up. However, we realized there was no way we were just going to throw away all the extra food, so we packed it up and sent it to a local retirement home where they gladly accepted. Even though I didn’t handle the planning, I would like to prevent a similar situation in the future so I would like to improve on competency CRDN 3.9 Coordinate procurement, production, distribution, and service of goods and services, demonstrating and promoting responsible use of resources.

The first two weeks of my newest rotation has already set the tone for the remaining time I have here. My preceptor is great, the people around us are super friendly, and working with food means that don’t go hungry often – which is a huge perk. Excited for what’s to come!

 About to eat ALL the fried chicken.

About to eat ALL the fried chicken.


References:

1. Saliakellis, E., & Fotoulaki, M. (2013). Gastroparesis in children. Annals of Gastroenterology : Quarterly Publication of the Hellenic Society of Gastroenterology26(3), 204–211.

King's Daughters Medical Center: Community Rotation, Week 7

I have finally finished up my last week of my community rotation. I say “finally”, but it went by in the blink of an eye and I can honestly say it was a very bittersweet moment for me. Working with the staff there at KDMC was a true treat and it was in an area that I love learning about: weight loss counseling, diabetes counseling, and just connecting with individuals on a 1-on-1 level. I believe if you’re going to make a real difference on someone’s life, you need to spend extensive quality time with that person and listen to their struggles.

In the last week, I was lucky enough to finally sit in on a psychiatric evaluation and the key component of that type of evaluation is simply listening. Normally, I wouldn’t have been able to sit in on these encounters but the psychiatric specialist thought this person was “normal” enough for me to tag along. The person was definitely pretty “normal”, but it was a little interesting because they had a real phobia of snakes. The specialist explained to me that this wasn’t just a common fear for this person; they had all the symptoms that would qualify their fear as a true phobia. Working with specialists like this made me realize there is so many psychological issues I may not be able to identify with an initial meeting with a patient or a client, and so a competency I want to work on is CRDN 2.6 Refer clients and patients to other professionals and services when needs are beyond individual scope of practice.

The next activity I got to partake in was analyzing about a month’s worth of a person’s food log. They were a diabetic and my preceptor wanted me to look it over and point out things she thought the patient could improve on and then turn it back into her. Throughout my 7 weeks of working with diabetics, I have started to notice some trends. The main trend is these patients tend to think carbs are “bad” and that since they are diabetic they should avoid them completely. This usually results in them opting for higher fat foods, which are also higher calories. I made sure to point out this patient was not eating enough carbohydrates at their meals and was consuming way too much saturated fat and calories in general. This combination, along with them not eating at consistent meal times throughout the day, was not going to end well if they kept doing what they were doing.

Finally, the last activity I got to do was presenting my Nutrition Presentation to the dietitians and nurses on-staff. It was extra special for me because my mom works at the hospital and she got to come down and listen to me speak. The topic was on weight loss nutrition and I got to deep dive into subject that I was already familiar with and combine them with topics we had discussed during my time at this rotation. I believe those who came to my talk were pleased with my presentation and they told me they learned a few things, which is always great. One thing I brought to their attention was the emerging research on the benefits of a high protein diet for those trying to lose weight. Antonio et al. (2014) was the first interventional study to demonstrate that consuming a hypercaloric high protein diet does not result in an increase in body fat. It showed that consuming 5.5 times (4.4g/kg/d) the recommended daily allowance of protein has no effect on body composition in resistance-trained individuals who otherwise maintain the same training regimen. I then followed this up with a paper by Møller et al. (2018) that showed a high protein diet (more than 2g/kg/d) had no effect on kidney function in pre-diabetic older adults and is completely safe to consume higher amounts of protein. They were open-minded on the subject and this made me happy that I got to share the new data with them. This led me to believe I did well on CRDN 1.4 Evaluate emerging research for application in nutrition and dietetics practice.

 

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References:

Antonio J., et al. (2014). The effects of consuming a high protein diet (4.4 g/kg/d) on body composition in resistance-trained individuals. Journal of the International Society of Sports Nutrition. 1550-2783;11-19.

Møller, G., Rikardt Andersen, J., Ritz, C., P. Silvestre, M., Navas-Carretero, S., Jalo, E., … Raben, A. (2018). Higher Protein Intake Is Not Associated with Decreased Kidney Function in Pre-Diabetic Older Adults Following a One-Year Intervention—A Preview Sub-Study. Nutrients, 10(1), 54. http://doi.org/10.3390/nu10010054

 

 

King's Daughters Medical Center: Community Nutrition, Weeks 5 & 6

These past two weeks of my community rotation have given me the full spectrum of differing workloads. Some days I was doing busy work at the office and other days I was giving a nutrition presentation to the diabetes support group. Or, in the past few days, I was in Lexington meeting with my classmates and offering mentorship to the younger CP students. So I’ve been all over the place learning new things, but also teaching others at the same time. These activities have given me the opportunity to see both sides as a student and a mentor.

The first “activity”, if you can call it an activity, was the busy work my preceptor had me do. Typically when I come in to work, I sit in on the surgical weight loss assessments and the diabetes counseling with the patients who come through the Center for Healthy Living. However, since I do this every single day, my preceptor knew of something else I could do. They have a large amount of surgical weight loss evaluations that have not been filed and alphabetized in their appropriate folders –this became my new task for a few days. I feel like it would be common for most people to be annoyed and see this as busy work, but I saw it as realistic and practical. Whatever career I pursue, I will likely have to endure some type of “busy work” that will be necessary for me to do my job correctly.

The second activity I experienced in the past two weeks was having the opportunity to teach the diabetes support group. This is a monthly support group that has been going on for years and my preceptor allowed me to teach the first half of the class. The main topic I focused on was eating healthy on the go. This included eating at airports, eating at the gas station, packing for staying at a hotel, having healthy snacks readily available, and more.  I also touched on the importance of fiber intake for diabetics. Post et al. (2012) showed that an intervention involving fiber supplementation for type 2 diabetes mellitus can reduce fasting blood glucose and HbA1c. This suggests that increasing dietary fiber in the diet of patients with type 2 diabetes is beneficial and should be encouraged as a disease management strategy. The class consisted of 10-15 people over the age of 55 in a fairly informal classroom-type setting. This was a competency I felt I did really well on - CRDN 3.4 Design, implement and evaluate presentations to a target audience.

Finally, the last activity involved heading up to Lexington to meet up with all my classmates and Mrs. Combs and Mr. Schwartz. This was a great time to catch up with every one and see how their internships were going. It was also really interesting to listen to all the presentations from each student. Our respective research proposals and case study’s from our MNT rotations were the focus over the two days. I believe I did okay with presenting my research proposal, but it showed me that I needed to work on competency CRDN 1.3 Justify programs, products, services and care using appropriate evidence or data. My research takes place in my current outpatient setting and part of the research involves assessing the current validity of our weight loss programs here. By being aware of available research on my topic and the differing programs out there will allow me to assess more accurately.

Overall, the last two weeks has provided me an opportunity to enhance my public speaking and presentation skills, while also reminding me that you sometimes have to do the “dirty work” that is required to get the job done. One is not more important than another and both are crucial to developing a well-rounded set of skills as a dietitian. 


References:

1. Post RE, Mainous AG, King DE, Simpson KN Dietary fiber for the treatment of type 2 diabetes mellitus: a meta-analysis. J Am Board Fam Med  2012;25:16–23.

King's Daughters Medical Center: Community Nutrition, Weeks 3 & 4

Another two weeks down in my community rotation and I am still learning at just as rapid pace as I did in the first two weeks; not only learning more, but getting to experience more as well. The three main activities that I got to enjoy in these last two weeks were attending the KAND conference, attending a nutrition-focused physical exam seminar, and having the opportunity to enhance my on-on-one counseling skills with the surgical weight loss patients.

It was so nice to be able to see everyone who went to the KAND conference. I was able to meet up with my classmates and talk about how our internships were going. Some of them had more pleasant stories than others, but it was all apart of the learning process and they were hopeful for the future rotations. We were able to enjoy some amazing presenters who talked about a plethora of different subjects from dealing with IBS patients to learning how to properly taste multiple bourbon samples. There was a ton of networking and just all-around positive emotions that were spread throughout the conference. It was great to “nerd out” with fellow peers who were passionate about the same thing – food. I was also extremely surprised when I found out I had won the Outstanding Dietetic Student Award by the KAND committee. I was overwhelmed with joy and honored to receive it. This is a competency I think I did well on: CRDN 2.9 Participate in community and professional organizations.

The second activity I got to partake in was the seminar for the nutrition-focused physical exam. My preceptor and a few other of the dietitians from the hospital decided they wanted to go to earn the CEU’s and they asked if it was okay if I could tag along. So when I found out I got the green light, I was pretty pumped because this is a new field of expertise in the dietetic world. According Pogatshnik et al. (2011), a nutrition-focused physical examination (NFPE) can help dietitians create a more effective care plan and determine appropriate interventions for patients receiving nutrition support. Laboratory findings are often inconclusive, and physical assessment can help to identify nutritional abnormalities. Dietitians can increase their proficiency in clinical skills by learning physical assessment techniques. The seminar was held in Huntington, WV and lasted about 4 hours. The presenter was a clinical dietitian who has had years of experience and did an amazing job presenting and answering any questions that the other dietitians had. We got to learn about how to assess each area of the NFPE and we even got to spend some time practicing with the others in the audience. They had a case study example that we got to navigate through and try to diagnose the patient provided. It was a fun day and we got to experience a ton of good information that we can put into practice as this subject starts to become more and more of the norm.

Finally, the last activity I was able to participate in was the surgical weight loss counseling. In the last two weeks, the dietitians on staff let me shadow them and sit in on sessions with their patients. I didn’t usually say much and I got to soak in all the information because it was all new for me, too. However, this time I got to perform the initial assessment on the bariatric patients that came in for surgery. These are the patients who were there for their very first time and all I basically had to do was ask questions about their history. These questions could be about what diets they have tried before, why they want to do the surgery, if they’re ready for long-term changes, etc. This task was just hard enough for me to get my feet wet with handling a counseling session by myself. The goal is to eventually go through an assessment all by myself, but there is still a lot of material for me to go through in the surgical weight loss handbook, so I will need a little more time before I can flow through the entire hour-long assessment without any other guidance. This is a competency I would like to improve on: CRDN 3.6 Use effective education and counseling skills to facilitate behavior change.

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It still flabbergasts (love that word) me how quickly these weeks have been going by. To think that I am already more than halfway through my second rotation of this internship is astounding. It has been such a great time and I’ve enjoyed learning from my preceptors immensely. I am excited to finish this rotation up and enter into what comes next – foodservice. 


References:

1. Pogatshnik, C, Hamilton, C. Nutrition-focused physical examination: skin, nails, hair, eyes, and oral cavity. Support Line. 2011;33(2):7-13.

King's Daughters Medical Center: Community Rotation, Weeks 1 & 2

Starting at a new rotation can always be scary, but two weeks in and I already feel at home here at King’s Daughters Medical Center. I am currently with the surgical weight loss team, who also specializes in non-surgical weight loss and diabetes counseling. The team has been extremely helpful and welcoming to me. Being the only guy in a team that consists of all females has been a fun experience already, and they like giving me a hard time, but it’s been fine because I have no issues returning the favor. ;)

During the first week, it consisted of me shadowing the dietitians and sitting in on their sessions with patients. For the most part, I didn’t really say much until I was more comfortable with the dietitian I was working with and after I figured out the “flow” of how each of their sessions would typically go. Then, once I was comfortable, I would slowly start to chime in a little more during the counseling sessions when I thought I could add to the information the dietitian was providing. It worked out well because we could bounce ideas and suggestions off one another to help the patient better reach their intended outcome. It was also neat because my preceptor and I got to discuss some critical thinking questions once the patient had left, which usually resulted in digging through some scientific research to gain some clarity on our discussion. I feel like the current body of literature is constantly evolving, so this is a competency I would like to work on -- CRDN 1.4 Evaluate emerging research for application in nutrition and dietetics practice. One research meta-analysis I ended up looking at was by Cheng et al. (2017), who looked at the comprehensive summary of surgical versus non-surgical treatment for obesity. The pooled results of primary endpoints (weight loss and diabetic remission) revealed a significant advantage among surgical patients rather than those receiving non-surgical treatments (P < 0.05). Furthermore, except for certain cardiovascular indicators, bariatric surgery was superior to conventional arms in terms of metabolic secondary parameters (P < 0.05).

Towards the end of the first week, my preceptor and I got to sit down and plan out my goals and what I could possibly experience while I was working here.  We were able to fill out my competency fulfillment plan and make sure I knew exactly what I was doing while I am at the facility. I felt like this is a competency I did well on because I am very open to new experiences and communicating what shortcomings I believe I have at the moment that could be improved on while I’m here at KDMC-- CRDN 2.12 Perform self-assessment and develop goals of self-improvement throughout the program.

I have really enjoyed trying to keep up with everything the dietitians tell their patients, because a lot of it is new information for me to learn as well. Specifically, a lot of the information on diabetes patients was new to me. I have a general understanding of diabetes and how it works, but in these sessions we get into the nitty-gritty details of how to time your insulin, where to inject it, when to eat, how many times to eat, etc. For one patient, I got to sit in on their session with the nurse and with the dietitian so I could follow along with them through the counseling experience.

Finally, the last activity I got to experience was sitting in on the behavioral health class for the pre-operation patients about to forego bariatric surgery. This class covered all the mental health aspects of how the bariatric surgery will impact your life. Some topics discussed included dealing with friends and family around the surgery, dealing with emotional hunger, hormones, learning healthy behaviors, etc. I am very interested in the psychological side of obesity and it’s been fun for me to witness first-hand what is going on inside the mind of these patients living through it.

The first two weeks have been a complete success and I’ve already learned so much when it comes to an outpatient setting. I couldn’t ask for a better team and better environment, so I’m excited for the weeks ahead. 

  Just a candid shot of me working SUPER hard.

Just a candid shot of me working SUPER hard.


References

1. Cheng, J., Gao, J., Shuai, X., Wang, G., & Tao, K. (2016). The comprehensive summary of surgical versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomized controlled trials. Oncotarget, 7(26), 39216–39230.

Our Lady of Bellefonte Hospital: Medical Nutrition Therapy, Week 9-10

It blows my mind that I am currently typing my final blog post as my first rotation comes to an end. It feels like yesterday I was just trying to navigate through the massive snow storm on my first day to find out where the dietitian’s office was even located. Then, today was my first day at my new rotation.

Talking with the patients, assessing their needs, and actually seeing your care help the patients was extremely gratifying. Being in the hospital is almost never fun for these patients. Often, they’re sick, hurt, impatient, scared, and just want to feel better so they can go home. Knowing this, when you see that you’ve made a positive impact on their lives, it can mean a lot to both of you. It’s how I felt after helping this one patient who was obese and was having bowel issues – she just couldn’t keep any food down, but she finally had her surgery. However, she was afraid to eat whole foods again due to the fear of not being able to tolerate them. She expressed her issues with me and I wasn’t 100% sure on how I should approach the situation. So, I told her I would go discuss with the other dietitians and come right back up to her room. After discussing, I returned back to the room with a full low FODMAP that she may be able to tolerate and she was so filled with joy. Seeing someone being relieved of their worry because of you is one of a kind. I feel like this is a competency I did well on because I had to go the extra mile to figure out what was best for this patient - CRDN 2.7 Apply leadership skills to achieve desired outcomes.

After I took this patient their handout for the low FODMAP diet, I wanted to review up on some of the available literature on the effectiveness of this treatment. To my luck, I found a recent meta-analysis from 2016 that included 6 RCT’s and 16 non-randomized interventions on the effects of a FODMAP diet on IBS, IBD, and other gastrointestinal symptoms. This analysis concluded that there was a significant decrease in IBS symptom severity scores, significant improvements in the IBS quality of life scores, and FODMAP diets significantly reduce symptom severity for abdominal pain and overall symptoms. Overall, the analysis supported the efficacy of FODMAP diets in the treatment of gastrointestinal symptoms (Marsh, et al., 2016).

Another activity I got to partake in in the last two weeks was the use of a calorie count consult from the MD. It was actually for a homeless patient who was recently admitted into the hospital and diagnosed with severe protein calorie malnutrition. I had to work with the PCT for 3 days to get an accurate calorie and protein count of how much he was taking in each day. Then, I had to compare his average calorie and protein intake to what his estimated needs were. Since he was taking in slightly less than we wanted, we had to add a supplement to each meal to bump up his intake.

Finally, the last activity that really stood out to me was my presentation of my case study to the  other dietians in the office. I had a fun time creating and presenting this patient I had been following for such a long period of time. The other dietitians offered awesome feedback to what I should keep and what I should consider including for next time. Their main points were focused on the assessment of the patient and the overall understanding of his case of the disease state, so I think a competency I could work on would be CRDN 1.6 Incorporate critical-thinking skills in overall practice. I would say the coolest (but also sad) part of the entire case study is what happened on my very last day of my internship. This patient was initially admitted in January and then discharged towards the end of the month. Well, I return to work on my final day and look down at my list of patients for the day and it just so happens the guy I did my case study on was readmitted into the hospital due to relapsing. It was a very real moment for me and also sad just because I know he had high hopes last time he was discharged, but his struggle continues. 

  Great 10 weeks. :)

Great 10 weeks. :)


References:

1. Marsh, A., Eslick, E.M. & Eslick, G.D. (2016). Does a diet low in FODMAPs reduce symptoms associated with functional gastrointestinal disorders? A comprehensive systematic review and meta-analysis. Eur J Nutr. 55: 897. https://doi.org/10.1007/s00394-015-0922-1.

Our Lady of Bellefonte Hospital: Medical Nutrition Therapy, Week 7-8

Another 2 weeks down and it flies by just as fast as the others have. It’s honestly hard to believe that I only have 2 weeks remaining until I am finished with this clinical rotation and begin my community rotation. I’m still learning at an extremely rapid pace and finally starting to refine my skills in a clinical setting.

I am still rotating each week with a different dietitian and this week I was with the oncology department and the behavioral unit. There were three main activities that stuck out to me: getting to sit in on some outpatient counseling, giving a nutrition seminar to the behavioral patients, and getting to fill in for some of the other dietitians who were gone this past week.

One of my biggest interests as a dietitian is to help counsel people in a one-on-one setting and this week I got to do exactly that. Well, I didn’t do the majority of the counseling, but I got to observe and add in my two cents when appropriate. I have had some experience counseling people in the past, but this time was completely different because of the type of person who came in for help. This person was not motivated at all to make a change – didn’t like any fruits or vegetables, had a myriad of diseases, and was over 300 lbs – so it was interesting to see how the dietitian I was shadowing handled it. We were able to set a few goals for them, but it would be surprising if they actually followed through with any of them. It showed me that a core competency I want to work on is [CRDN 3.6 Use effective education and counseling skills to facilitate behavior change.]

There were also some of the dietitians who were sick or out of town this week, so it was a new experience for me to help out and take on some of the work load for their patients. This ranged from anybody who had a broken foot in the orthopedic unit to a patient who was in ICU that had overdosed on a new drug called Flakka and was on the ventilator. Because of being fairly successful at this, I think a competency I did well on was [CRDN 2.4 Function as a member of an interprofessional team.]. We also decided to have a little empathy for our patients and all the dietitians decided to try the Ensure and Glucerna shakes that we gave our patients. Some tasted better than others. :) 

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I also got to work with a different group of individuals in the behavioral unit (detox and acute). These are people who struggle with alcoholism, behavioral disorders, and/or substance abuse. I was able to conduct a nutritional seminar for these patients, for those who were interested in coming. To my surprise, they had some solid questions for me and most of them were actually eager to learn something. The environment was much more laid back than my normal classes I put on for the cardiac and pulmonary rehab classes. It was basically a question and answer the entire time and completely informal. I had a blast talking to them and I think they really enjoyed my help.

It was after I got done talking to some of those individuals with alcoholism when I came across one of them who was at risk for refeeding syndrome. Refeeding syndrome is a syndrome consisting of metabolic disturbances that occur as a result of reinstitution of nutrition to patients who are starved, severely malnourished or metabolically stressed due to severe illness. I had learned about refeeding syndrome in class, but I wanted to dig a little deeper. I found some great information from Stanga et al. (2008) that determine the following as main points: always be aware of the circumstances in which the syndrome is likely to develop; refeed slowly and build up the macronutrient content of the feed over several days; monitor the patient frequently; anticipate the additional requirements, particularly of phosphate, potassium, magnesium and thiamine; and minimize salt intake, unless the patient is salt depleted.

Next up is the final home stretch at my last rotation. I am pumped to see what lies ahead.


References:

1. Nutrition in clinical practice—the refeeding syndrome: illustrative cases and guidelines for prevention and treatment. Z Stanga, A Brunner, et al. European Journal of Clinical Nutrition volume 62, pages 687–694 (2008)

Our Lady of Bellefonte Hospital: Medical Nutrition Therapy, Weeks 5-6

During this rotation, I have been working with 4 other dietitians. Each week I get to shadow/work with a different dietitian, which is really cool because each one has their own floor that makes up a separate disease state/patient condition.

Since this was week 5, I have had the chance to work with every single one of the dietitians and now I am back to the beginning with my main preceptor. She has the 3rd floor, which is mostly the pulmonary patients. This includes a lot of patients with pneumonia, flu, CHF, COPD, etc.

Working with her meant I also got the chance to teach a pulmonary rehab class. If you read back in my last blog post, you’ll see that I got to teach the cardiac rehab patients and I really enjoyed speaking with all of them. This one was around the same amount of people, around 10 to 12, but this time I had to speak on the importance of having good nutrition with the COPD disease state. When you have trouble breathing, it can complicate a lot more issues than you would expect while eating. I didn’t have much experience teaching on this subject so it was a little challenging for the first class I taught. However, the second time rolled around later that afternoon and it went much smoother. Speaking in front of people always gets better with more reps.

During the 6th week, I got to work with a separate dietitian who had the ICU patients. These are patients who usually can’t tolerate eating much at all and typically need tube feedings. This is one competency that I do think I have improved on, which is [CRDN 1.6: Incorporate critical-thinking skills in overall practice.]. I say that I have improved because during the first time around with this dietitian, I had to ask many more questions about the tube feedings and how to go about caring for these types of patients. This time I think I had a much better handle on things. However, I still realize that I do need more clinical knowledge as a whole, and I think this competency is something I could do better on [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.].

Since I need to improve, I wanted to dive a little deeper into the research on a problem we faced in ICU throughout the week. We had a patient who wasn’t tolerating the tube feedings (diarrhea) and we were trying to figure out what the best option was. I decided to look up if there was any difference between intermittent tube feedings and continuous tube feedings. Ciocon et. al found that patients tolerated intermittent tube feedings better than continuous, specifically in terms of diarrhea. I found this super useful and made a note of it for future reference.

Finally, this last week, we also got to participate in Legislative Day in Frankfurt, KY at the Capital. There were multiple speakers on various topics and I think everyone left with a better perspective on Bill 200. It was cool to meet some of the legislators and to tour around the Capital building. My group got to meet up with the Owensboro Representative, DJ Johnson. He said he was on board with Bill 200 and thought it made a lot of sense to make sure the food waste was minimized as much as possible.

From the look of this pic, I think it was a successful trip. :)

DHN Legislative Day.jpg

References:

1. Continuous Compared With Intermittent Tube Feeding in the Elderly Jerry O. Ciocon, MD, Daisy J. Galindo-Ciocon, PHD, RN, Charlotte Tiessen, RD, Diana Galindo, MD. 1992. Journal of Parenteral and Enteral Nutrition. Vol 16, Issue 6, pp. 525 – 528.

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