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.

Holidays away from home

Yeah, Yeah, I know, this post about Thanksgiving and Christmas is a little late...  OK, fine, A LOT late.  I don't mind, though... do you?

Discovering American Buffalo at Shelby Farms  in Memphis
(largest metro public park in America)

For this government internship, I luxuriously receive all government holidays off; however all of my vacation days have been pre-planned.  The Friday after Thanksgiving was allocated for one vacation day, as well as a few days around Christmas.  Unfortunately, on a small stipend and these limited days, my travel home to Florida was limited.  Specifically, it did not happen. :(  I wondered if I would bake a chicken breast in my apartment by myself on Thanksgiving and Christmas, but alas I was embraced by so many loving people that that idea was far from reality.  So many, in fact, that I had THREE Thanksgiving dinners and one Christmas dinner!  I know what you are thinking, it is tough to make room for one gluttonous dinner, let alone three!  I managed it with Thursday Thanksgiving breakfast, Thursday late afternoon dinner, and Friday late afternoon dinner!

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!)

The Veteran Clockmaker

Here we go again with more patient and Dietetic Internship adventures at the Memphis VAMC!(Previous week's blog posts can be found to the left under the navigation by date headings.)

DIETETIC INTERNSHIP: Weeks 6 & 7  (of 41)

Weeks 6 & 7 - Home-Based Primary Care

Nationwide, the VA has a great program called, Home Based Primary Care(HBPC), which sends medical practitioners to a patient’s home if travel for an appointment would prove extremely difficult.  The HBPC team includes doctors, nurse practitioners, nurses, dietitians, social workers, etc…  The frequency of specialty visits is dictated by the patient needs, but he or she is usually visited by at least one practitioner every other week.

Entry into one’s home can be a very private and privileged experience.  A person’s home is very personal and unique, and entering such a dwelling offers a glimpse of a his or her life.  This week, I entered >15 different homes (with another RD), and each presented exceptionally different experiences.  Some were in quite insalubrious neighborhoods, while others were more nourishing.