Search Chasing Jessie

Saturday, June 29, 2013

Doing the Impossible

DIETETIC INTERNSHIP: Weeks 13 & 14  (of 41)
Weeks 13 & 14 - Nutrition Support, continued

My Nutrition Support rotation continued for two more weeks…  Now I am rounding in the Medical ICU, or really just what people normally refer to as the “ICU.”  This rotation, Nutrition Support, feels a lot like Walt Disney’s words coming into reality: It’s kind of fun to do the impossible.

So what is Nutrition Support?  Supporting a patient on enteral nutrition or parenteral nutrition.  Enteral nutrition, sometimes referred to as tubefeeding, feeds through a feeding tube that goes through the nose, or directly into the stomach or small intestine.  After a feeding tube is placed (by an RN), nearly every clinical dietitian can determine the right formula and quantity of formula to match the method of feeding.  Parenteral nutrition, on the other hand,  is a very delicate procedure that feeds by IV directly into one’s veins.  The IV line deposits carbohydrate, crystallized amino acids (protein broken down into all of its molecular parts), and lipids (i.e. fat) directly into the bloodstream mere inches from the top of the heart.  To say the least, the determination of appropriateness of such a feeding route, and the calculation of the specific, proper formulation, is a very delicate manner.  To me, feeding someone in this manner is a bit like doing the impossible; after all it has only been around, successfully, for less than 40 years!  (If you are interested, here is a journal article on its history.) 

Parenteral nutrition requires a multi-disciplinary team ("Nutrition Suppport Team") due to its complexity and risks:  at least a medical doctor, pharmacist, and registered dietitian.  The Director of the Nutrition Support Team at the Memphis VA Medical Center is also the Director of Surgery, for example.  She is one SMART cookie!  Those outside these fields frequently don’t understand it, including some seemingly ‘smart’ folks…   For example, while observing a surgery in the OR, the anesthesiologist & I had the following conversation: 

Wednesday, June 12, 2013

Adjusting to a New Norm

Dietetic Internship adventures at the Memphis VAMC continue(Previous week's blog posts can be found to the left under the navigation by date headings.)

DIETETIC INTERNSHIP: Weeks 10, 11, & 12  (of 41)
Weeks 10, 11, & 12 - Nutrition Support

After 2 brief weeks with inpatient clinical dietetics, I was doused headlong into my next big rotation: 5-weeks of intensity in Nutrition Support.  Warning: This title is deceptive.  The Nutrition Support registered dietitian may cover various wards, but at the Memphis VA Medical Center, she covers ICU, Surgical ICU (SICU), and is a team member of Nutrition Support team.

The ICU patient is one of the most complex patients, and has the highest death rate of any ward, up to 20% average across the US.  The ICU is also the site with the highest number of medical errors due to the complexity of care.  This place is intense.  INTENSE.  I was turned loose as the nutrition expert on the ICU team (decisions reviewed before action, of course!) among medical residents and doctors.