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!

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.

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.

failing to blog in over a month is not evidence of an event-free six weeks. there is a lot to report, many interesting patient-stories to tell. i’ll try to hit the highlights over a few separate posts…

right now i’m scanning over past patient lists and chart notes to jog my memory of who i’ve seen over the past few weeks.

a “patient list” is just as it sounds — a list of patients that my preceptor (MP) is following. MP and i use the list to plan out our day and to prioritize what patients we’ll see based on any new consultations receieved (from the docs) or based on each patient’s risk level (i.e. their level of nutritional need/acute illness).

a “chart note” is a written record of the care provided to a patient. please forgive me if this is tedious. at our hospital, all of the charting is done online, which is extremely convenient. laptops are scattered throughout the building, allowing us to look up past notes, lab values, medication lists, past medical histories from anywhere, anytime. computerized charting also allows us to write our assessments in a clearer way (read: full sentences with no need to decipher horrible handwriting). the ability to cut and paste information is also priceless — we don’t have to spend time rewriting past medical histories or quotes from other practitioners — we can simply ctrl+v it into our notes. awesome.

most hospitals are still charting by hand, which tends to be messy and time consuming. i’ve absolutely learned that if clinical dietetics is in my future, e-charting may be a necessity.

today i saw my first gastrointestinal (GI) pediatric patient: a 15 yo boy who had just been diagnosed with ulcerative colitis.

ulcerative colitis (UC) is no fun. UC is a type of inflammatory bowel disease (IBD) characterized by a colon (large intestine) that is covered with ulcers. there are a number of etiologies: environmental, genetic, autoimmune, some think infectious (from a virus/bacteria/etc).

ulcers in one’s colon often leads to intense pain, diarrhea, bloody stools w/ mucus, and sometimes anorexia (loss of appetite) due to the eventual aversion to foods that trigger the symptoms.

the main medical nutrition therapy (MNT) for this type of patient in the acute hospital setting is first and foremost to stop the pain and inflammation (in this case with pain meds and steroids). once the symptoms are under control and the flare up has subsided, the second step is to get the patient on a low-residue (low fiber), low-fat diet with lots of fluids and fat-soluble vitamin supplements to allow the bowel to heal and replenish lost electrolytes and vitamins.

my job was to educate the 15 yo about his GI and his new condition. my main goals were to make a diet plan for him and his family to fall back on during the next flare-up, or teach him how to manage the condition through diet (e.g. lay off high-fiber, high-fat, high-caffeine foods during flare ups).

it was a major bonus that both mom and dad were in the room for the entire visit. they learned a lot as well.

we also talked about how the patient will slowly figure out his own individual “triggers,” or foods that bring on an acute flare-up. his triggers may be caffeine and stress, while his mom says she reacts to alfredo sauce (she also suffers from UC).

before i visited the patient, i really had to think about how i was going to educate a 15 yo boy about his bowels. not an easy sell. i had to figure out a way to make the patient care about his condition and take a bit of interest in the plan of care.

my idea: i would focus on his height. my thinking was that 15 yo boys (and girls) are really still thinking about linear growth, which at 15 is absolutely still happening and absolutely tied to nutrition. as a child becomes malnourished, the first thing to go by the wayside is weight, then height, then brain growth (in pediatrics, brain growth is measured by head circumference).

so, my plan with this kid was to start the conversation with my goals to continue to see nice, normal weight gain (only possible through good eating/bowel health), so we could protect his linear growth (height).

i think i got through.

more to come!

another great week under my belt. three down, nine to go!

last week i rotated to a new pediatric dietitian, who covers gastrointestinal (G.I.), pulmonary, neurology, and hemotology/oncology (blood disorders/cancer) pediatric services.

by the end of the week, my preceptor (MP) was giving me my own patients, which i was able to see from start to finish!

what this means: MP gets “assigned” patients based on what services she covers. so, for example, when an MD orders a “nutrition consult” in one of MP’s services (i.e. a kid is admitted with a GI, pulmo, neuro, or heme/onc problem and has a nutritional need), she researches the pt (past medical history, current medicines, reason for hospitalization, reason for nutrition consult), visits the patient, makes adjustment to the patient’s diet (or tube feed or TPN feed) as needed, and writes a note in the pt’s chart using the nutrition care process (NCP).

the NCP is the A-DIME process i spoke about before. the NCP is the method of charting that includes an (A) assessment, (D) nutrition diagnosis, (I) nutrition intervention (what you plan to do for the patient), and (ME) plans for monitoring and evaluating the patient.

so, again, after a week of learning how to assess the needs of MP’s patients, by friday, i was able to see two of my own patients from start to finish! granted, i had MANY questions for MP to answer along the way. MP also accompanied me into patients’ rooms during my visits, and she gave a final edit to all of my chart notes, but… it felt pretty wonderful to start to be independent.

some notable cases: i provided an initial assessment of a 19 yo male with cystic fibrosis (CF). FYI: CF is a heritable disease characterized by abnormal secretions (by the pancreas, lungs, GI tract, etc). this leads to abnormal digestion, decreased lung function (among other systemic problems), which can lead to increased nutrient needs (it takes a LOT of energy/calories to breathe when your lungs are filled with thick mucus, and it’s nearly impossible to digest lipids, protein, and carbohydrates when your pancreas isn’t producing enough enzymes).

thus, the medical nutrition therapy (MNT) for CF patients is a high-protein, high-fat diet with supplemental enzymes and fat-soluble vitamins. anything we can do to increase intake, absorption, and subsequent weight gain is a good thing.

a second case: a heartbreaking 7 yo girl with acute lymphocyte leukemia (ALL), or a type of blood cancer. the nutrition consult was to help the patient find foods that taste good while she undergoes chemotherapies. (FYI: chemotherapy can lead to dysguesia, or a change in taste, and sometimes aguesia, the absence of taste, and it can also suppress appetite).

the best part: this little girl wanted to talk to me. i love it when the kids will talk while the parents patiently listen. the girl’s problem seemed to be a mixture of dysguesia (meat didn’t taste good to her; chocolate chip cookies did!) and simply a dislike for the hospital food.

since she had been steadily losing weight, i educated her on tips for combating dysguesia and appetite changes, i encouraged her to focus on ordering/eating the foods that she knew tasted good, and i added supplements (calorically-dense chocolate milkshakes, puddings, etc.) to her daily meals.

i’ll be checking up on both patients next week to see if the supplements/tips have helped their weight and appetite.

i also got my first bit of experience calculating TPN this week. TPN (total parenteral nutrition) is formula/nutrition delivered through the veins and requires careful planning and calculation.

more to come!

two weeks down, 10 to go…

last week was incredibly busy due to an increased patient load for my preceptor (MP). it’s hard to tell whether MP had an increased load or if i was simply slowing her down.

i also attended the Nutrition and Food Service (NFS) Department meeting as well as the pediatric RD meeting.

overall, the NFS department seems to have high employee satisfaction scores, except among the dietitians. chief complaint: they want more help. the good news: the hospital bigwigs have just approved a new budget that includes monies toward the hiring of new registered dietitians (RDs). this made everyone happy.

last week I worked on two calorie counts. a calorie count is simply a tally of a patient’s intake (usually kept by the nurse or the patient’s caregiver for 2-3 days). it’s the RD’s job to calculate the total calories and protein consumed and make recommendations regarding whether or not the patient is meeting or exceeding her needs.

i was surprised by how much estimation the RDs use. for example, the calorie count might list “four waffle fries” without any indication of whether the fries came from inside the hospital or if they were smuggled in by a family member. because the nutrient density of a french fry can change depending on what oil it was fried in, how thick the potato was cut, etc., estimation can lead to a less precise nutrient analysis.

MP mainly used Calorie King to estimate the kcal and protein in items that may have varying nutrient contents (like french fries); however, she used the exchange system to analyze items that have standardized contents (e.g. 8 oz. of whole milk has 150 kcal and 8 grams of protein. period.).

one has to assume there is a better way to calculate total intake, especially at a hospital that uses computrition. i assume the hospital’s computrition system knows exactly how many calories and grams of protein are in the waffle fries the kitchen pumps out. perhaps this would be a better way to handle calorie counts for foods produced within the hospital?

more to come!

today i spent most of the day in the PICU (pediatric intensive care unit) with a different preceptor, while my preceptor was out for the day.

two interesting cases: a 17-year old girl had burns covering 55% of her body while another boy had multiple tumors in his meninges, which are thin layers of tissue that cover the brain and spinal cord. we spent the day analyzing their tube feeds and determining whether or not what they’re receiving meets their needs and making recommendations for changes.

we also saw an interesting FTT (failure-to-thrive) kid in general peds who was having a hard time swallowing. we visited the patient and the parents to obtain a diet history, which is basically collecting what, how much and how often they usually feed the patient at home.

this is an interesting case because there are a few etiologies (causes) for his FTT. for one, the child is super active (burns a lot of calories) and resists eating (the parents said that it takes ~1 hour to feed him one scrambled egg). that immediately sent up a red flag — any parent who allows a full hour for one egg is a) probably not using the best feeding strategies (i.e. not in a high chair, not face to face, not very responsive or interactive) and b) is probably allowing the child to immediately burn off whatever is being put in.

the best part: by chance, we were able to witness a feeding during our consult. the parents’ feeding style was, in fact, not very responsive. (FYI: “responsive” refers to an infant feeding style where the parent and child are making eye contact, the parent is talking to the child and maybe reinforcing that the food is yummy, and it also involves some modelling, or literally showing the baby how to chew, swallow, etc.)

the patient was holding food in his mouth for extremely long amounts of time (which made us think there was some sort of physiological swallowing issue). this is also called “pocketing” food in his cheeks. also, because his mouth was full of food for so long, he sort of forgot it was there and at one point he tried to cry out and actually aspirated (breathed in) the food, which caused him to choke and vomit. his parents were also sort of mindlessly spooning in more food, even though his cheeks were distended and full. i’m not sure if this is because we were in the room and they were preoccupied, or if this is par for the course for the type of feeding style they use.

also, it’s interesting to note that the patient was sitting on his dad’s lap facing outward as dad was reaching around and spooning food in. there was absolutely no interaction between them and the baby repeatedly pushed food away.

not surprising that i was thoroughly interested in this case. (FYI: i’m 99.9% sure that i’m going to become a lactation consultant after graduation, but now i’m also wondering if i can, in some way, specialize in infant/pediatric feeding/education as a whole).

i’m a bit confused about whose job it is to make sure these parents are educated on proper feeding techniques once poor habits are identified (in the hospital or anywhere else). is it the WIC dietitian’s job? my preceptor said no. is it our job in the clinical setting? again, my preceptor said no. is it their family general practitioner or occupational therapy or a speech language therapy’s job?  still wondering…

back to general peds tomorrow. i’m going to need to put in a good hour or two one night this week to create some cheat sheets to help me through all of the calculations that many of these dietitians can quickly rattle off.

i’m starting to wish that my clinical experience was going to be longer than 12 weeks, which i never thought i’d say.

more to come!

what a long day!

MP has been covering the NICU (neonatal intensive care unit) for the past two days while the main NICU dietitian is on vacation.

the NICU is a whole other ball of wax compared to general peds, since it deals mainly with intensely sick premature babies and their intensely tiny nutrient needs. my MP has been overwhelmed covering the extra caseload (even though she’s completely capable), so it’s been interesting to observe the differences between the NICU and general peds.

we’ve been doing a lot of recipe formulation (read: mathematics), which entails turning a child’s nutrient needs (calories, grams of protein, fluid, etc) into a recipe using household measurements that any average mother (or father) can understand. it’s a lot of work, but i’m going to be so rockin’ in algebra by the end of the summer.

for example, let’s say a child (based on her recommended daily allowances, or RDAs) has been getting 75mL of fortified breastmilk every three hours, and the total mixture has 24 kcals (calories) per ounce. it’s our job to calculate what that means as far as what she is receiving all day and also calculate a recipe in tablespoons, teaspoons, etc, to enable the parent to recreate that mixture once the patient heads home.

it’s a lot of math, but it’s super-gratifying to check up on a kid a few days after creating a new feeding regimen and find she’s growing right on track.

heading home to make it an early night. i’ll be with a different MP tomorrow (who just moved to NC from NYC, actually), so it should be interesting to see another RD’s perspective.

more to come!

one week down, 11 to go. i can already tell that this summer is going to fly by.

last thursday and friday were both busy days for my preceptor (MP), hence they were busy for me. but that just means i was able to witness and learn a ton.

one main highlight: MP and i gave a diet instruction to a mom whose 11-month old son had a cleft palate repair. he was put on a mechanical soft diet, which, essentially means that all foods need to be pureed or cooked soft with nothing stringy, sticky or crunchy. also, all bottles/sippy cups should be valve-free, or free flowing (when it tips over, the fluid will come pouring out with no suction involved).

we downloaded some education materials for the mom from the ADA Nutrition Care Manual and MP also consulted me for my opinion on the overall plan of care which was cool.

MP and i also sat in on rounds with the peds general and peds renal (kidney) teams. if you watch any sort of hospital night-time soap opera/drama TV show you pretty much know what ”rounds” is. if not, rounds consists of the entire medical team (attending physician, interns, nurses, pharmacologists, dietitians, etc) talking about each patient in the unit and discussing that day’s plan of care based on new information gathered that morning.

the PMA (peds general) rounds were especially cool as the attending physician (main head honcho) really likes to do what she calls “family rounds,” or discussing the patients in their rooms, in front of their families. this gives all of us a feel for any of the patient’s clinical manifestations (symptoms you can see) as well as the social situation (based on who is in the room/supporting the patient, what the patient’s social/economic situation, etc). 

this attending is also fluent in spanish, which is a huge asset for any health practitioner in north carolina. makes me want to take some spanish classes.

anyway…. back to work. it’s monday at noon, and we have a FULL afternoon of consults and follow-ups. also, i just got confirmation that i will, in fact, be in peds for the first 6 weeks of the internship (which i love!).

more to come!