third week of june in the MICU (read: mick-you)

after six weeks in peds, i returned from camp to begin my first week of adults rotations in the MICU. pretty intense.

the MICU (Medical Intensive Care Unit) is a section of the hospital dedicated to providing critical care services to adults with major organ failures (heart, lungs, liver, kidneys, etc.) or with multi-system failures. “critical care” basically means around the clock, comprehensive supervision.

MICU patients often present with (come to the hospital with) respiratory failure, sepsis (massive infection), shock (extremely decreased blood pressure that reduces blood flow throughout the body), hemorrhage, renal (kidney) failure, liver failure, neurological illnesses, and multi-system organ failure.

so, how do dietitians fit in? the MICU RD makes nutrition recommendations (deciding whether or not to feed, what to feed, and at what rate one should feed a patient) based on a patient’s day-to-day, and often hour-to-hour, respiratory and hemodynamic status (read: how are they breathing and what are their blood tests telling us about their nutrition status?) while also keeping in mind the patient’s medications, treatments, past medical history, etc.

nutritional needs change based on what types of treatments patients are receiving. for example, patients that are intubated with mechanical ventilation (breathing with the aid of a machine) have decreased energy needs because the machine is doing most, if not all, of the work of breathing. in plain english: they may require less calories to do the day-to-day work of living.

deciding when and if to feed a MICU patient is tricky business. in peds, the RD is constantly trying to prevent weight loss so as to protect the child’s overall growth. in pediatric malnutrition (when a child isn’t receiving enough nutrients to promote growth), weight loss occurs first, then a child stops growing (length ceases), then brain growth (or head circumference) declines. scary stuff.

in adults, one goal is to protect lean body mass, or provide enough calories, protein, and fluid so the patient doesn’t begin to break down her own endogenous sources of protein (i.e., break down muscles like the heart or the diaphragm for energy).

in our hospital, adult patients are “flagged” once they have been NPO (nil per os, or nothing by mouth, or they haven’t had anything to eat or drink) for longer than three days. enteral nutrition (via a tube) or parenteral nutrition (via the veins) are both options for nutrition support if the patient is unable to take anything by mouth. once the route of nutrition is decided, the RD must choose a formula with adequate and appropriate amounts of calories, protein, electrolytes, fat, fluid, and in some cases, carbohydrate.

i’ll try to find an interesting MICU case i worked on, as it’s a pretty daunting task to try to describe the inner workings of the MICU, or the nutritional needs of the critically ill, in laymen’s terms without an example.

more to come!

off to camp!

the third week of june was spent working as a nutritionist/counselor for a week-long summer camp for kids with diabetes. the week served as as sort of extracurricular week within the context of my internship, so i was able to receive credit for being a camp counselor. awesome.

the main qualifications for working as a “camp nutritionist” were to be a registered dietitian (RD) or be on your way to receiving your master’s degree in nutrition/RD status, have experience in diabetes management or education, have past experience working with children, have a readiness to adapt to camp life/work as a team member, and willingness to donate a week of your life to living at camp. done!

i didn’t have much prior experience with diabetes education per se, but i did have a solid grasp of the biochemistry involved in an insulin-dependent system. i also knew a bit about diabetes nutrition management/the consistent carbohydrate diet from my coursework and hospital/food service experience.

before camp, my main role was to familiarize myself with the campers’ past medical, activity, and dietary histories so that i could assist in their nutritional care during camp. in plain english: i had to assess what campers were eating and how much they were exercising at home to correctly adjust their meal plans at camp.

while there may have been some campers in attendance with type II diabetes, the majority of them had type I, or insulin-dependent, diabetes. i was assigned one age group (the youngest group: 8-9-year olds) to follow throughout the week and help them eat the correct number of carbohydrates and bolus the correct amount of insulin.

people with diabetes focus mainly on controlling their carbohydrate intake since it is the nutrient with the biggest impact on blood sugar levels. it’s a delicate balance to give someone with diabetes just enough carbohydrate to sustain them throughout the day without pushing them into hyperglycemia (high blood sugar).

a little background: type I diabetes is a disease in which a person’s pancreas does not produce enough insulin. this type of diabetes is an autoimmune disease, which is why it usually shows up in childhood – it’s not a disease that you “do” something to get. type II diabetes, on the other hand is showing up in more children than ever, which is, unfortunately, due to the fact that kids are “doing” something, or more appropriately “not doing” something – eating well, exercising, etc.

an autoimmune disease (AID) is a disease in which a person’s immune system mounts an attack against it’s own body. type I diabetes is an AID in which a person’s immune system destroys the beta cells of the pancreas, which are the cells that produce the hormone insulin.

normally, the pancreas senses the levels of sugar, or glucose/carbohydrate, in a person’s bloodstream and releases just enough insulin to usher the sugar into muscles, fat cells and other tissues for use as energy or for storage.

in someone with type I diabetes, when carbohydrate is eaten it is absorbed into the bloodstream and the pancreas isn’t able to respond by releasing insulin, thus the glucose isn’t able to enter a person’s cells and blood glucose levels rise.

this is a huge problem as cells depend on glucose/sugar for energy. if glucose can’t enter the cell, the body has no choice but to break down other materials for energy. these “other materials” are usually fats.

while this may sound like a good idea to use fats for energy, burning only fat leads to ketoacidosis, or the acidification of a person’s blood due to the accumulation of ketones (an acid byproduct of fat breakdown). confusing? just know that the accumulation of ketones is a life-threatening situation.

people with diabetes routinely check their urine for ketones with ketone strips, as do some people on carbohydrate-free diets, like the atkins diet. these diets force the body into ketoacidosis. not good. thankfully, these diets are next to impossible for patients to maintain.

to sum it up: working with the camp nurses, medical staff and campers was really an amazing learning experience. i was exposed to the day-to-day maintenance of living with type I diabetes and i came away with an excellent understanding of how to educate kids about the nutritional maintenance of their disease.

a week in the PICU (read: pick-you)

the second week of june was spent in the PICU, or the pediatric intensive care unit.

the PICU is a section of the hospital reserved for seriously ill children whose medical needs require intensive monitoring and support. kids in the PICU are placed there, generally, because they need pressure support (i.e. they’re breathing with the help from a ventilator), constant heart/blood pressure monitoring, or because they are sedated (i.e. medicated until unconscious).

while i was able to see a lot of interesting cases and receive an introduction into the MNT (medical nutrition therapy) of critically-ill children often with multi-system failures… i also learned that the PICU is not for me.

my preceptor (MP) loves the PICU because of the critical importance of nutrition in the health and healing of these patients. she is constantly reading a patient’s lab values (electrolytes like sodium or chloride, minerals like calcium or phosphorus, or enzymes like alkaline phosphatase or creatine kinase) that signal whether or not an organ is working properly or that aid in the assessment a patient’s nutrition status, healing progress, or tolerance to feeds.

monitoring a patient’s daily and sometimes hourly course is absolutely a necessity for a PICU dietitian; however, this places her in front of a computer screen for hours reading laboratory values, culling through research to decide upon the best plan of care, and writing chart notes. often the only human interaction the PICU RD has is with the medical team to discuss the disease state or nutrition interventions.

while this is exactly what some RDs are looking for (my PICU preceptor especially), this internship has showed me that while i like researching and writing chart notes, i also love and need patient interaction.

if a PICU child is intubated and sedated (on a ventilator and knocked out by drugs), there is, obviously, very little patient interaction happening. parents are often in the rooms and can offer a bit of a human touch, but mostly the child is so acutely ill that parents rarely bring much information to the table past being an historian (i.e. telling us about the child’s past medical history).

i absolutely learned a lot about treating the acutely ill (and a lot about what i don’t know), but the PICU life may not be for me.