A coffee a day makes a registered dietitian?

At the end of the day on July 19^th, I was officially unemployed.  My dietetic internship was complete, I was a few weeks away from eligibility to take the Registered Dietitian exam (paperwork, etc), and I had a lot of studying to do BEFORE I would be prepared.  Alas once again I was a student with no job and at that moment, no credentials.  In the words of Scooby doo, “Ruh roh.”

After a few days of non-sense and reclaiming my house after 4 weeks of disorganization madness during Staff Relief and Graduation week, I embarked upon the daunting task of studying.  The RD exam costs a few hundred dollars to take it and I only intended to take it ONCE.  Each Dietetic Internship program (in my case, the Memphis VAMC) is ranked by multiple components, including the first-time pass rate of its graduates.  The Memphis Director let it be known that thus far she had a 100% success rate (against a national average of ~82%) and that she Would. Not. Accept. Anything. Less.  Fear tactic.  It totally worked.  That, and I am very thrifty.

Dietetic Internship Graduation! Week 41 of 41!

DIETETIC INTERNSHIP: Week 41 (of 41)

Graduation Week: Week 41 - THE LAST WEEK!!!

It felt like Staff Relief would never end but hallelujah it did and the last week of this Dietetic Internship has finally arrived!  Graduation week!!  This week spilled over with presentations, final training, and paperwork; no work days were completed in less than 10 hours.  To make this week even more memorable, on Tuesday morning I received a rather peculiar email; a fellow dietetic intern colleague Nick also received it verbatim:

“You provided patient care to a patient that has since tested positive for tuberculosis.  You provided patient care to “Mr. TB” on xx/xx/xx date, and have been exposed.  Please arrange to go to Employee Health as soon as possible to be tested for TB.”

Nick & I both received the email while in the office together.  I heard an awkward chuckle at the workstation behind me.  I read the email without fully comprehending it, then re-read it.  Before I realized it Nick & I were already in harmony through grunts and “uh huh,” logging out of our computers and nearly galloping to Employee Health!  As a reminder: TB tests require a small amount of innocuous TB strain to be injected to your forearm and then the ‘test’ is read 48-72 hours later.  Later that night I was at home regarding my forearm.  Not only had the area swelled, but also it was bright red with clear edges.  OH MY!  UH OH!  I was SURE I contracted TB!  To make matters worse, NPR was airing weekly stories on TB from across the globe.  I knew one thing: This was bad, BAD.  Like isolation and sequestration for months or even years, bad!

Dietetic Internship: Staff Relief

DIETETIC INTERNSHIP: Weeks 38, 39, 40 (of 41)

Staff Relief: Weeks 38 - 40

Finally!  The last phase of the Dietetic Internship is upon me: Staff Relief.  For three weeks, I will take over full responsibilities for one Registered Dietitian role at the Memphis VAMC, manage her floors, her patients, set follow-up dates, and complete other required RD administrative duties.  I have to see at least six patients per day, preferably 8, regardless of complexity.  Historically I have met with my preceptor each morning for her to parse out my daily patients; now I will decide and manage all 60 or so beds and determine my own priorities.  This step is like moving into adulthood.  Finally.  Undoubtedly full of challenges, too.

Alas, I did it!  I saw a WIDE variety of patients with different nutritional needs:   Bowel obstructions, Gastric cancer surgery, sudden respiratory failure and progression to vegetative state, emergency guillotine amputations below the knee because of horrible diabetes management, little old men that refuse to eat, pancreatitis, inguinal hernia repairs, and malnutrition.  I accompanied a cardiopulmonologist to the ER to watch him perform an emergency intubation.  NOTE: That is NOT a delicate procedure!  I watched a left and right cardiac catheterization (not part of RD duties, just interesting!).  I visited daily the sweetest 71-year old man w/ Parkinson’s disease that had severe GI issues and required total parenteral nutrition; he made my heart pour out with happiness and sadness simultaneously.

Specialty 2-week rotation to Florida!

DIETETIC INTERNSHIP: Weeks 36 & 37 (of 41)

Alternative / Specialty rotation in Gainesville, FL: Weeks 36 & 37

Hi ho, hi ho, it’s off to Florida I go!  My Dietetic Internship included a 2-week “Alternative / Specialty” rotation at a facility outside of the Memphis VA Medical Center.  It is the intern’s responsibility to seek out the location, find the contact information, and secure this bond.  What. A. Chore!  I wrote, I contacted, I searched for names, numbers, friends or family with whom I could stay for two weeks.  Honestly, it was all a bit stressful and at one point, I questioned why I was not just looking around Memphis and consequently happily sleeping in my own bed.  BUT.  My Internship Director kept telling us that often individuals find full-time employment at their Alternative Rotation site, and I wanted to make a thoughtful decision. 

Oak tree canopy

After a lot of contacts, I very happily secured a contract with the Gainesville, Florida VA Medical Center.  A long time ago (when I was a student at the great University of Florida), I made best friends-that-became-my-family in High Springs, FL, about 25 miles away from the hospital in Gainesville.  They accepted me for two weeks, as well as the VAMC.  Done!  Next step:  Drive.  It is a LONG way from Memphis to Gainesville, specifically nearly 700 miles!

Diabetic spirits

DIETETIC INTERNSHIP: Weeks 33 & 34 (of 41)

Intensive Diabetes Management: Week 33

Pediatrics: Le Bonheur Week 34

What type of pills would you like to take?

Let me be honest.  I didn’t take many (personal) notes during the above-named rotations.  I toiled, but I left significant lacunae in my bank of memories.  Here are a few memorable moments:

Intensive Diabetes Management was primarily outpatient driven and functioned like playing a game of Magnum PI crossed with Dr. House.  Patients come in reporting high and low blood sugar extremes with seemingly perfect compliance to medication and insulin.  Dietary compliance?  That is always questionable.  I saw patients with blood sugars ranging from 30 to 460 daily, and supposedly taking the correct dosage of insulin.  Riiiiiight.

Tell Me What You Eat

DIETETIC INTERNSHIP: Weeks 31, 32 & 35 (of 41)

Foodservice Systems:  Weeks 31 - 32
Culinary : Week 35

Where do Registered Dietitian’s work?  As of Oct 2013, there are approximately 89,000 RDs in the US and abroad, the vast majority of which (~70%) are employed in a clinical field (healthcare in hospitals, long-term care facilities, etc).  The other main RD fields are foodservice systems, and school foodservice.  Research and community dietetics round out the list.  Unquestionably, the preponderance of public opinion associates RDs commonly with “food” only despite its low occupancy.


     As soon as I utter the words “Dietitian,” most people:
             a) pat their belly or hips, grumbling out regrets regarding dietary intake;
             b) recall what was consumed at the last several meals; and/or
             c) silently, yet assuredly, bring food and weight to mind.
     It has not taken long to recognize this repeating response. :( 

Breastmilk, fiber, and fried rice

DIETETIC INTERNSHIP: Week 30 (of 41)

Women, Infants, and Children (WIC):  Week 30

WIC = Women,Infants, and Children.  Yep, that is all I saw this week during my week at WIC.  WIC serves the financially underprivileged through a nutrition commodity program.  Directly, no money changes hands, only vouchers and education.  Registered Dietitians play essential party to this transaction as the nutrition expert for the pregant and post-partum woman, and the growing infant or child.

In the weeks leading up to this week’s rotation, I was slightly apprehensive.  My assigned WIC clinic was at one of the least desirable shopping malls in South Memphis, known for its crime and tumbling desirability.  Yes, there was Macy’s, Sears, and close to Graceland, but the area has fallen from grace, and several armed security guards roam the corridors.  Two local friends warned me to not stay in the area after dark.  During my lunch breaks, I frequently exercise-walked the thoroughfares and browsed the shopping selections.  I unearthed several bargains, but constantly looked over my shoulder.  During one lunchtime saunter, my security was infinitely unmitigated as I spied one security guard plugged into the wall, focusing intently on his charging cell phone.

Going Back to School

DIETETIC INTERNSHIP: Week 29 (of 41)

School Food Service:  Week 29 - Memphis City Schools

Who remembers what it is like to be less than 10 years old?  What about in high school?  How did you respond in ‘social interactions’?  What did you like to eat?  When did you like to eat?  How much?

What an interesting change of pace to transition from medical maladies to school food service this week!  For one week my mind reverted to sophomoric ideologies and preferences; it was tougher than I remembered!  One day I worked as a Lunch Lady at an elementary school (what fun!), and one day at a high school (a bit nerve-wracking!).  Going back to elementary school was so much fun!  Not only were the cafeteria workers friendly and welcoming, the kids were hysterical.  I walked around talking to them about their favorite foods, favorite snacks, encouraging each to try different foods on their trays… generally forming a personal Inquisitorial Committee.  Before leaving the cafeteria, several kids insisted on sharing their love with me, passing me through lots of hugs, and “I hope you come back!” salutations.  The high schoolers, on the other hand, were not nearly as lovely.  It did not take long for me to read through the words and body language of the kids, recalling the constant turbulence of emotions.  I left that afternoon SO thankful of my age and perspective.  (That was a first; I usually lie about my age! J)

The Old and The Restless

DIETETIC INTERNSHIP: Weeks 26, 27, & 28 (of 41)

Vacation!:  Week 26

Geriatrics & Palliative care: Weeks 27 & 28

These next two weeks were filled with the old, the very old, the young old, and the very sick.  I spent two weeks alternating between Geriatrics (>65 years old, often inpatient 4-6 weeks for rehabilitation) and Palliative Care (less than 6 months to live).  I was full of emotions before this rotation began, knowing my past may interfere with my present.  Daily, valetudinarians dominated my workload, and I wobbled between emotions.

My past includes my father, a Veteran, who passed away at home 8.5 years ago.  He peacefully and painfully died at home, aided by personal administration of palliative sedation.  Any time some of these words are spoken within my earshot (particularly “palliative”), or in regards to a young individual, (my father was 54 years old), my nose begins to tingle and flare, my eyes open widely, instinctively searching my surroundings, reflective of my minds speeding thoughts and connections.  This rotation not only posed professional challenges of a new patient population and goals, but also of managing my own reactions.

Sight, Smell, Texture, & Feeling

DIETETIC INTERNSHIP: Weeks 24 - 25 (of 41)

Spinal Cord Injury: Weeks 24 & 25

The Spinal Cord Injury (SCI) population is a very unique group that ranges from tetraplegia (formerly known as quadriplegia) to paraplegia, with various stages of injury severity (complete v. incomplete) and mobility.  For example, an incomplete tetraplegic patient may walk with a cane or walker, but a complete paraplegia may not be able to turn him/herself in the bed, nor sit up.  Much of this has to do with injury severity.

I spent two weeks working with inpatient and outpatient SCI patients.  VA SCI individuals are frequently inpatient for extremely long durations; I visited with patients that had been inpatient for over 6 months or more!  Many SCI patients are quite healthy in mind, but uncooperative in body.  The injuries that resulted in SCI are far ranging, from a 32 year old enlisted officer that went butt over teakettle while mountain biking, to an older man that fell out of the top bunk of his prison bed.  One can only imagine that compliance to medication, which includes nutrition, is just as varied.  With some near complete immobility, nutrition is the #1 form of medicine… or the #1 form of disease.  

I had a blog post published nationally under the VA!  Read the original here, or below:

Every Body, Every Day: How to Get Fit

May 9, 2013 by Jessie Furman

How many times in one week do we hear about exercising? Eating right? Losing weight? Keeping our heart healthy? Many have heard and understand that exercising is beneficial for health; however, there are often many questions about exactly how much exercises is needed, the benefits to activity, what qualifies as exercise.

What does it all mean?

If your doctor told you that doing one thing for approximately 30 minutes per day, 5 days per week would significantly reduce your risk of:

Early death, coronary heart disease, stroke, high blood pressure, type 2 diabetes, breast and colon cancer, falls, depression.

Would you consider incorporating it into your life? It would cause no harm, only benefits, including health and financial gains. Would you do it? By now it is no surprise that this 30-minute per day “thing” is Physical Activity!

Watch this video, it is worth every minute:

How much?

Some physical activity is better than none.  For major health benefits the CDC , the American College of Sports Medicine, the U.S. Dept of Health & Human Services, and the American Heart Association recommend that adults:

The Administrative Side

DIETETIC INTERNSHIP: Weeks 20 - 23 (of 41)

Management: Weeks 20 & 21
Professional Development: Week 22
Research: Week 23

The Registered Dietitian’s exam includes various managerial topics, from theory (Maslow, Herzberg) to application (human v. technical v. practical skills).  In a pair with fellow intern Nick, we spent two weeks working with two different managers:  the Chief (of Nutrition & Food Services), and the Clinical Manager.  The tasks ranged from disciplinary proceedings meetings to face-time-only-required meetings to rudimentary analysis of current Clinical Dietitian medical chart documentation.  Meh.  While many people at my age are ready to progress beyond the day-to-day operations in their respective career and move into management, my feelings are slightly ill timed.  I suppose because the dietetics fields is a career change for me, I am entirely interested in solely patient care at this time.  Or perhaps I just want to stay away from financial analysis any time soon!?!  Regardless of sentiment, I like healthcare!

Tagxedo & Chasing Jessie awesomeness

I found this great website that allows one to customize a (pre-loaded) shape with words, colors, font types, and themes!  What is the standard shape representation of dietitian?  An APPLE, of course!  Here is the Chasing Jessie (Dietetic Internship only) word art!

Make your own at Tagxedo.com :)
(It is legitimate, this is not a spam posting!)

Rock On: The Kidney Stones!

DIETETIC INTERNSHIP: Weeks 18 & 19 (of 41)

Renal (Kidney) Disease

The renal world (i.e. kidneys) poses a lot of complications for patients in many arenas, from medication management, coordination of many healthcare specialists, and very importantly, drastic nutrition alterations.  Unless you develop some form of kidney troubles, most people have no idea what the kidneys do, where they are located, or how many we have?...  (Psst!  In general, your two kidneys are located in the back of the abdomen (see a picture here), working hard all day long to filter blood (remove waste products, create urine), maintain fluid and electrolyte balance, and secrete hormones to control blood pressure!)  Everything you know about healthy eating recommendations is (nearly) reversed in kidney disease.  Let me explain...

Standard healthy eating advice:

Eat whole grains, buy wheat bread instead of white, brown rice, not white!  Eat more fruits and vegetables!  Consume low-fat dairy 3 times per day!  Limit your sodium intake!

Oh wait, you have chronic kidney disease (CKD) and/or on dialysis?  Screeeeeech!  Cancel nearly ALL of those recommendations! 

MIFA & Meals on Wheels

DIETETIC INTERNSHIP: Week 17 (of 41)
Week 17 - MIFA

The past few weeks/months have been very busy in my world as a VA Dietetic Intern.  Actually, it varies by Intern, as every rotation has different requirements and associated assignments, which may demand a few extra hours that week, or 10-20 hours more.  The latter category was starting to get tiring, in addition to putting in excess hours for research projects.  Just in time, a rotation week away from the VA!

The Metropolitan Inter-Faith Association (MIFA) was founded just after the assassination of Martin Luther King, Jr in Memphis, TN (1968).  This organization manages a number of different programs from emergency family services to Senior citizen assistance, including administration of Meals on Wheels.  Briefly, Meals on Wheels is a government-funded program that provides home-delivered and congregate meals 5-days per week to nutritionally at-risk individuals over age 60 years.  MIFA’s research and studies have shown that congregate and home-delivered meals benefit the community immensely.  It is estimated that there is a substantial 11% return on investment for these programs in a community.  Nutritional programs help seniors in need by reducing malnutrition, falls/fractures, and depression.  According to MIFA, last year they provided 447,967 meals to Seniors!

Halitosis, Grouchiness, and Orgasms

DIETETIC INTERNSHIP: Week 15 (of 41)
Week 15 - Psychology, Oncology, Cardiology

This is week 2 of a very wide mix of patients: oncology, cardiology, and psychiatry.  I have a personal interest in psychiatry patients, and needless to say, those conversations were *always* very interesting.  Because I do not like to poke fun at others when the handicap is not within their realm of control, I will reserve most of those interactions.  One, however, was embarrassing enough to share… (See “Friday’s patients”).  Here is a brief chronicling of my second week:

Monday's patients were mostly uneventful, but that did not last long this week...

Tuesday’s patients were generally well and good, but the last patient of the day had some of the worst breath I have ever smelled.  He recently had a severe stroke, yielding impaired speech, so I had to look and listen close.  I almost gagged as I leaned in closely.

Wednesday's patients took Tuesday's breath to an entirely different level.  

Swapping weighty stories & Ted Talks

DIETETIC INTERNSHIP: Week 15 (of 41)
Week 15 - Psychology, Oncology, Cardiology

Weight management education and counseling is a required, regular aspect of a Registered Dietitian’s arsenal, particularly in America’s overweight/obesity cauldron.  As I counseled one patient this week on weight loss he listened patiently, but had a pressing question on his mind.  His question did involve food, lifestyle, or habits, but was more personal in nature: 

Patient:     “Have you ever been fat?”

Me:            Taken off guard, I unremarkably replied, “Huh?”

Patient:     “Have you ever been fat in your life?”

I learned that this man, severely obese, was not interested in taking any advice or guidance from someone that had always been thin, never struggled with larger weight problems (literally, not figuratively), or has never felt the social stigma of largess.  After sympathizing with him, and empathizing with him, we had a some frank discussions about his weight (and mine), choices, and future options.  He was receptive towards me, and recounted stories of previous weight coaches and dietitians that left him more cynical than engaged.  Personally, I have not been "thin" during any part of my life, but characteristically normal weight to slightly overweight.  We exchanged ideas for over 30 minutes, a very long time by inpatient standards, and when I departed, I could feel his sense of empowerment and renewed vigor.  If felt really, really good.  He asked if he could make an appointment to meet with me on an outpatient basis after his hospital stay.  That is what I call a professional compliment!

It is times like these that I realize how much impact each of us can make on a daily basis.  We don't have to be in healthcare to make a difference in someone else's life.

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: 

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.

Being a Positive Influence

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 8 & 9  (of 41)

Weeks 8 & 9 - General Medicine

In this rotation I experienced my very first inpatient setting…  the General Medicine wards.  I had become so used to Outpatient that I wasn't exactly sure how/what went on in the hospital.  On Day 2 I was quickly caught up to speed as I saw an obtrusive red sign on the patient’s door, nearly shouting at me, “Caution! Caution”  Not knowing what to do, I called my preceptor (which is like a mentor and boss during a rotation), “Umm, help?!”  

She graciously informed me that this patient was under isolation and droplet precautions, and I needed to re-outfit myself.  She helped me get suited up in a head-to-toe yellow gown, face mask, and gloves… then I entered the room.  What kind of encounter was I headed to?  Aliens?  Nope, a patient with the flu and other complications such as COPD and hacking every 2 minutes.  “Contact Precautions”  I don’t want your flu or anything else!  I suited up many, many more times over the course of the day, and the following two weeks.  (It is really hot under a face mask!)