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: 

Anesthesiologist:             What group are you with?

Me:                                  I am part of the Nutrition Support Team.
Anesthesiologist:             Ok.  If I am hungry in the middle of the night, can I call you for a BLT?
Me:                                  (Pause while considering my response)… Umm, NO.
Anesthesiologist:             Well when I think of Nutrition, that’s what I think of...
Me:                                  Unless you'd like to eat that BLT through a feeding tube, I can't help you…
Anesthesiologist:             Hmm.  Well I sometimes drink my margaritas through a straw!

I don’t know about you, but I generally think of the anesthesiology field as one that typically requires top notch intelligence, and this conversation was far from it.  He wasn’t joking until the very end when he realized how insulting he was.

As mentioned in my last post, I have learned that a mental adjustment is required to work in the ICU, yet sometimes the numbness is elusive.  I experienced some very somber moments.  It has been a sad week and a half seeing patients fall from ostensibly stable, albeit not well, conditions, to end-stage collapse.  I had several patients on parenteral nutrition, that literally saved their lives, and calculated a dozen different enteral nutrition feeding regimens, also life-saving.  It was frequently very hard to not create an emotional attachment to the patient or family, particularly when deaths are common.

I had one patient, a 55 year old man with Stage IV COPD (Chronic Obstructive Pulmonary Disease).  I was consulted to see him because of his poor dietary intake.  At my first visit around 8:00am to encourage a little breakfast, I told him, “I’ll be back in about an hour with your medical team during Rounds.”  Beneath the oxygen face mask he was wearing, a sly smirk crept across his face as he seductively told me, “I’ll be looking for you…” with a wink.  He was physically in pain, but clearly well within flirtation limits!  Later that day, I checked in on him again, and met his 3 adult children.  He was sitting up eating, oxygen mask off, smiling at my entry.  Warm feelings flooded me as he was surrounded by family love, not dependent on a face oxygen mask, and enjoying lunch.

The next day during ICU medical rounds, I stood in the background as my eyes watered up.  His family stood around the room weeping and distraught.  The patient was mildly irate, agitated, and unstable, all symptoms of excessive CO2 and insufficient O2.  Seeing this patient’s aggressive and rapid turn for the worst, his children emotional at his side, and his misplaced playfulness that existed a mere 18 hours prior, all had me in terrible tears.  The next day?  He passed away.

Nearly since birth, my mom tells me I have been beleaguered with insatiable empathy, eyes watering up almost immediately if anyone else around is crying.  Not much has changed as I have progressed into adulthood, including now working in a hospital full of weeping family members.  It is easier to adjust to a new norm when a patient is comatose or in a vegetative state, but those that smile back at you really yank the emotional connection wires.

Fall leaves failing in my apartment complex
(Yes, I know, this post/picture is a bit delayed!)

Daily during medical rounds, the “team” was sometimes 12-14 people large, or as small as 6.  We were composed of an attending (supervising) physician, several medical doctor residents, several medical doctor interns, a pharmacist, pharmacy resident, dietetic intern (me!), and occasionally nurse practitioner interns.  We could field a baseball team with enough for pinch hitters and relief pitchers!  I really enjoyed learning from all of these disciplines, and learning I did!  ICU does not have a “specialty” medical condition, other than everyone is critical.  I can’t say enough how much I enjoyed the learning environment and the daily challenges of intensive/critical care.