DI Days: From the Fervent Files of S. Fink, RD to Be

Sitting with Uncertainty (and other things I’ve felt while living unemployed…)

Hello beauties!

A happy mid-June to you all. I hope the weather is beautiful where you are. If not, get a load of this:

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I’m as shocked as you are. This is San Francisco, for Pete’s sake.

Well, last I checked in, I had just completed the final rotation in my dietetic internship. Uncertainties abound, but the newness of being free from supervised practice hours for the rest of my career was enough to keep at bay the flaming ball of anxiety that often inhabits my gut.

Prior to completing my internship, I firmly proclaimed that I required some down time, during which I could focus on studying for my RD board exam, and with money I had saved, I could get myself through a few more months unemployed. After passing the exam, I would carry on with my job hunt, warp speed – factor 10.

Well, to my utter shock, as soon as I had about 3 weeks left of my internship, I awoke from a haze to find I had been frantically perusing nutrition job websites, and noticed fingers that looked like mine typing away at cover letters and requests for references. What. Is. Happening?!

I wish I could say I caught myself in this old behavior, realized I wasn’t giving myself the unstructured time I so wanted and deserved, closed my laptop, and refocused my energy on passing my exam while enjoying life around me. Alas, this was not the case.

A number of weeks into practicing my daily routine of wake up, coffee, procrastinate, job hunt, “organizing” (shuffling things around until piles look manageable), listening to 1/4 of an Inman RD exam review track, and back to “organizing”, I had a nice little epiphany at which I so peacefully arrived by having it slapped upon my face.

Through networking and good fortune, I was put into contact with several people who were offering jobs that looked promising. After phone conversations and/or email correspondence, these opportunities looked like potential hires. They were jobs that I would be completely happy exploring, and I thought it would take away the anxiety I have felt relating to the dreaded day I run out of money. Well, time and time again, after informal interviews went as perfectly as they could have, I was told I would be a great candidate for the position, but right now they were looking for someone who had already passed their exam.

Alright – what’s the big idea, Universe? I was told early on in my plight into dietetics that many companies are ok with hiring prior to passing your exam, with the expectation that you pass within a certain amount of time from hire date. But that was proving wrong over and over again.

And then I remembered… Isn’t this exactly what I asked for? Didn’t I say I wanted and needed time to focus on this exam, and getting my life together post-internship? And didn’t I predict how I would struggle to just sit back and ALLOW this to happen?

Hm… Seems like the Universe just might have my best interest in mind here.

So currently where I sit is here:
Going against the voice in my head that tells me I’m not good enough because I get to live life on my own schedule these days, I have put the job hunt on hold. I am mostly focused on studying for this exam, and on appreciating what else I have going on, from a blossoming social life in a fantastic, still relatively new city, to community involvement and being of service to others. I have ACTUALLY done some legitimate organization which looks like this — a calendar where I can view things both weekly and monthly, noting sections of my exam review to go over each day to keep me on track to be as prepared as possible come test day. My exam is scheduled for July 23, which gives me over a month from right now to prep. I’m sure this time will fly by, so I’m avoiding the mind set that I have plenty of time and can get it done when I feel like it, which has often plagued me in the past; however there is enough time between now and the test for me to not be so susceptible to full-fledged conniption-style panic attacks if I only get through 5 pages instead of my intended 6 on any given Tuesday (if you don’t believe this to be a possibility, you were fortunate enough not to know me circa 2012).

For those fellow RDs to be who are curious about how I am studying and what materials I am using, I am going through Inman’s Review of Dietetics, and listening to the CDs where she reviews each domain and notes specific important details. That’s all I’ll say for now, and hopefully I can return in about a month to tell you that what I did actually WORKED, and share more at that time.

Until then, I will be sitting in some discomfort, and remembering to refrain from complaining about receiving the things I’ve always asked for.

Keep smilin, lovelies. Our futures are lookin damn bright.

<3,
Samantha

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Weeks 29 – 36: The FINAL 8 in School Nutrition Management

Well, it’s been a long road, but I can finally say with pride rivaled only by exhaustion that I have COMPLETED my dietetic internship!

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School nutrition management was my final rotation, and it was an experience unlike most of the others. Something I enjoyed was getting to work with a team of managers who worked in non-nutrition disciplines. For most of my 8 weeks, I spent time with our Food Service Director, a Manager in Training, our Associate Director, and worked closely with our head chef and catering manager as well. My rotation took place at San Francisco State University.  As I may have explained in previous posts, my internship was completed (love putting that in the PAST TENSE!) through Morrison Chartwells, a subset of Compass Group. Compass Group has a multitude of sectors, which provide food and nutrition services to establishments from hospitals, to schools, to business and industry settings. Morrison is the sector of Compass that serves healthcare establishments, which is where I did my clinical rotations. Chartwells is the sector that serves schools (and Chartwells Higher Ed, to further categorize, serves college campuses). My experience was unique in that I was working with Chartwells Higher Education, which works on college campuses – most other interns in my program were rotating in K-12 Chartwells accounts.

 

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Now that that’s out of the way….

 

My school nutrition rotation taught me a lot about management, and working with a team in which you are often the sole nutrition representative. I did have the opportunity to work with the Regional RD, Laura, who oversees Chartwells Higher Ed accounts. However, this was a long distance relationship, and  Laura did not have a scheduled trip out to SFSU during my time there. She was always available by phone and email, and was a large part of my learning experience in this rotation. Not having an RD present at the site on a daily basis taught me many times over to be proactive and independent.

Chartwells at SFSU incorporates a concept called Balanced Kitchen, which I was so excited to be a part of. Balanced Kitchen focuses on wellness on college campuses. At one point, I conducted an audit to ensure the dining center was meeting the wellness criteria for this concept – and our SF State champs did very well! I remember being a freshman in college, and staying well with healthy foods was such a challenge. It is great to see higher education moving in a direction that promotes the importance of a healthy lifestyle.

 

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Some of the criteria for Balanced Kitchen (aka Balanced U), and what the dining center strives to promote.

 

This was a project-centered rotation. In these 8 weeks, I think I completed upwards of 10 projects – and all of them took some serious time commitment! Some highlights:

 National Nutrition Month Activities:

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Me, beaming in the presence of my food models. Typical.

 

Nutrition Educations:

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Weird shadow on my face… But here I am giving a lesson on eating local and seasonally. My favorite educational tool right now is my local foods wheel. Ask me where you can find one!

 

Participation in Sustainability and Real Food Events:

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IMG_7790 A real local food-focused event!

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Put on a Farmer’s Market

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Enjoyed soo much delicious local produce.

 

Stress Reduction Fair:

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Focused on how to use good nutrition to keep stress in check! So much fun talking to students – and I met someone I’ve communicated with in the blog world! Amazing.

 

and Staff Trainings, and Food Service & Sanitation Audits (not pictured, because not that exciting – bein’ honest, folks).

 

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By the end of my rotation, I had made some strong connections with Compass employees at SF State, and I feel this rotation was the best opportunity to get to know some of the higher-ups who work for corporate! Getting to know some of the big wigs who manage entire regions was not only inspiring, but also allowed me to make an impression, shake some hands, and learn more about Compass as a whole.

 

As this blog is about honesty, I don’t want to leave out how much I struggled to get through this last rotation. With 8 weeks standing between me and RD eligibility, the to do list seemed forever impending. It’s not that the rotation was extremely challenging – I have been SO grateful to be done with clinical, and the stress level was NOT THE SAME here. But I did feel often paralyzed when I looked down at the list of projects to complete, and it even took me a few weeks to get started on some. But as of posting this, my assignments are COMPLETE, and I am awaiting the OK to sign up for my RD board exam (eeek!). This is a good reminder for me that it will all get done if I work toward it, but I have to remember to stay calm, get focused and organized, and just keep moving forward.

 

Well, folks, that wraps it up! Thank you to everyone who continued reading through my experience! I hope I was able to shed some light on the experience of dietetic internships for those of you embarking on this path. If you have questions, or just want to let me know how I’m doing (or how YOU are doing), please drop me a line below, or shoot an email over to thenourishedsoulblog@gmail.com.

 

This may be the end of my 1240+ supervised practice hours, but don’t you worry – there is still plenty of living, studying, and trying not to have panic attacks that I’ll be continuing to write about. Stay tuned, beautiful people! The best is yet to come over here.<3

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Weeks 23-28: Long Term Care and Community Nutrition

 

 

Every time I realize my clinical rotation is completely behind me, I feel completely shocked. Clinical rotations were something I had been anticipating since I came to understand what exactly happens in a dietetic internship. I am so excited to be moving down this path so quickly, and can’t believe the speed at which it’s flying by.

 

Immediately after my clinical rotations, I began the next two weeks in long term care, at a place called St. Paul’s Towers in Oakland, California.

 

Long Term Care: St. Paul’s Tower’s, Oakland, CA

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Older picture, but it’s still this HUGE!

 

St. Paul’s Towers is what is referred to as a Continuing Care Retirement Community, or a CCRC. By definition, CCRCs offer living facilities across all levels of care, which include independent living, assisted living, and skilled nursing (aka SNF). Here is a link to a basic description of each level of care: Long Term Levels of Care.

One of the jobs I worked before starting my dietetic internship was as the Dietary Director of a skilled nursing facility. With this under my belt, I felt I had already gained a fair amount of exposure to the job of a dietitian in a long term care facility. As it turns out, I was correct, but of course had volumes more to learn.

Fortunately for me, St. Paul’s happened to be going into mock survey during my first week there. Mock survey is something that, to those with a bit of knowledge of regulations in skilled nursing, sounds very scary, but is actually a positive thing. To start, I will explain the dreaded SURVEY. Every skilled facility has a survey “window” – for example, the SNF that I worked at had a survey window from April through July, if I recall correctly. What this window means is that any time during these months, surveyors who are usually sent from the state or federal level can show up at a facility and will audit everything from nursing to medical records to dietary and nutrition, looking for any errors  — anything at all you’ve done incorrectly or inadequately over the last year. So, survey itself is definitely SCARY. But MOCK survey is a company’s way of preparing for the true surveyors. During mock survey, the overarching company that runs the facility will send their own representative to audit all of these areas, and act exactly as a surveyor would. It is still terrifying, as each department (very much including nutrition) is looked at on such a microscopic level, that you can basically expect that any mistake you made over the last year will be found, addressed, and acted upon to correct. But, while this induces every self-critical voice in a young dietitian’s mind, mock survey is a good thing, as it is not put in place to get everyone in trouble, but to catch mistakes and assign them a plan of correction before the actual survey happens. Because the thing about a true survey is that if they catch too many mistakes, or just a small number of mistakes that show to cause harm to a large number of residents, the facility can have major penalties, and even be shut down completely.

 

So, it was great to have exposure to this process. When I was at my SNF about a year ago, I never had the… pleasure… of undergoing survey – but we were all constantly on edge, prepping for them to walk through the doors at any moment, so I was familiar with how to prepare for a survey. But getting this additional opportunity to hear everything from the preparation phase through the exit conference where the mock surveyor shares all of her findings with us was very beneficial.

 

A large portion of the week was spent shadowing and observing, but I also got a ton of hands on experience doing kitchen audits, dining room observations, and clinical assessments. My favorite part of my 2 weeks here was how creative my preceptor liked to get to bring a little extra joy to her residents. Mondays she took a little time to make hot chocolate and deliver a cup to any resident who was interested. One day per week she also would deliver fresh baked cookies to each resident. All of these practices that the RD implemented were a great way to add a little excitement to each week, boosted morale for employees (who got sweeties too!) and also acted as a great method for sneaking in some extra calories for those residents experiencing difficulty with weight maintenance!

 

Overall, my Long Term Care rotation was a great experience, and allowed for some unexpected new exposure. Next up was Community Nutrition at WIC!

 

Community Nutrition: WIC (Women, Infants, and Children)

The day after LTC was completed, I jumped in my lil’ Kia Sportage, and enjoyed a solo roadtrip down the California coast to spend the next 3 weeks at Normandie WIC near downtown Los Angeles. WIC is a supplemental nutrition program that serves low income families, assisting with food and providing nutrition education and counseling. The program serves pregnant mommies-to-be, and continues to assist as long as the family remains eligible until the child is 5 years old. Additionally, if the mother miscarries, services are still available up to 6 months after end of pregnancy. Different food packages are provided to these families, a picture of which is below (my WIC rotation was done in California – this is a picture of Florida WIC’s food packages, but they are similar):

 

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Supplemental Food Breakdown

 WIC will provide supplemental nutrition for the mother while she is pregnant, and will continue to do so after her pregnancy if she is breastfeeding. As the image above indicates, food packages vary based on whether the mother reports she is completely breastfeeding, mostly breastfeeding, or only providing some breast milk, or none at all.

 

WIC provides special WIC checks which can be used at participating stores for to obtain these foods. Participants can tell if a store will accept their WIC checks by looking for this image:

 

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During this rotation I learned so much more about the challenges that come with breastfeeding your child – although at the same time, I was reminded of all the incredible benefits both mother and baby receive when breastfeeding is made a part of the child’s first year. I was so happy to be reminded of the preventative benefits of breastfeeding, like decreasing disease risk and risk of obesity and cancer for both mother and the baby. Additionally, the emotional bonding that occurs between mom and child from skin-to-skin contact is truly amazing. And, of course, the nerdy nutrition girl that I am, I would be remiss not to mention the nutritional benefits of breastfeeding right away. WARNING: If you do NOT wish to get nerdy with me, please skip ahead to the next paragraph. Hello? Anyone left? Awesome, I knew I could count on you… So, later on in pregnancy, the mother’s body does begin to produce breast milk. However, the milk at this stage is what is referred to as colostrum – it is a substance that is a bit more yellow in color, and is made up of mostly protein. When you feed your baby right away with this early breast milk, they tend to see an array of benefits. Also, it just so happens that the nutritional makeup of colostrum is just EXACTLY what the infant needs at that early stage of life – now it’s pretty hard to dispute nature in all her perfection, am I right?

 

Now, if you’re just joining us, let me assure you of what a fun time we had in science land…

 

During this rotation, I was required to be very proactive in making sure I got the experience I needed/wanted. It was difficult to gain hands-on experience with counseling and educations due to a few limitations. Firstly, I did not have access to the computer charting system, since I was only at this site for 3 weeks. The computer was pretty imperative in conducting a counseling session, so most of what I did was observation, while providing input when it came time to conducting educations. The second and very significant challenge and limiting factor here was the language barrier. With only 3 years of high school Spanish under my belt, I knew I would not be able to have intellectual conversations about nutrition, nor convey all the information and passion I normally feel capable of communicating. I had been warned that when working at WIC, it is HIGHLY beneficial to be bilingual (at the very least), but I must have underestimated just how beneficial. It took me a few DAYS to be able to even observe anything because everything was being conducted in Spanish, Armenian, Russian, or Korean (and then some…). It was only later in my rotation that I mustered the confidence to decide that I could at least observe in Spanish, at which point I learned that I had a basic enough understanding of the language to at least follow along (although I was correct in feeling I could not communicate on my own…).

 

Given these significant limitations, a lot of the benefits that came from this rotation came in the form of projects that I asked my preceptor to be a part of. I requested to be given assignments, like creating handouts, which I could work on during the day as I was waiting for a counseling or education class in a language I could understand. During the course of my 3 weeks, one handout I created deals with what is safe to eat during pregnancy.

I also got to work on a presentation that I gave to the staff on my last day on a topic of their choosing. The staff requested dietary carbohydrates, weight loss, and calories in food – so I chose to address carbohydrates, and encompass the other two within.

A link to both of the projects is availabe on my online portfolio (click it, click it!!!).

My WIC rotation was a nice break from the hustle that was my clinical rotations. And I so enjoyed my time in Los Angeles, where I got to experience being a nutrition professional in my hometown, and got to spend three whole weeks with family and old friends.

 

Reminder from Mom...

Reminder from Mom…

Surviving 3 weeks of LA traffic, and remembering to BREATHE

Surviving 3 weeks of LA traffic, and remembering to BREATHE

Spending time with some of my oldest friends...

Spending time with some of my oldest friends…

...and the best family.

…and the best family.

And takin' in all the beauty.

And takin’ in all the beauty.

After WIC, it’s hard to believe, but I’m on to my next and FINAL rotation: School Nutrition Management. With about three weeks left at this point, you can expect the summary of that rotation shortly.

 

And a QUICK NOTE to those of you who went through the dreaded DICAS match these past few months: if you matched, CONGRATULATIONS! It’s an incredible accomplishment, and you have many challenges and some incredible learning experiences ahead of you.

 

If you didn’t match, just remember how AMAZING you are. As a reminder, I did not match my first time applying either. And as it turns out, not matching put me exactly where I need to be in my life in so many ways. If you’re lookin’ for a pick me up, check out this post I wrote the night before my first, unsuccesful match, and reposted a year later. And if you just need to remember that the world is good, please view this Buzzfeed post on baby elephants learning to use their trunks — I promise it will at least make you smile.

 

Thanks for tuning in, everyone. And stay tuned for my next and FINAL post as a dietetic intern!

 

Love Yo’self.

Weeks 13-21: Cardiology, ICU, Eating Disorders, Staff Relief

It seems we’re developing a motif here, as this post will continue to cram 5+ weeks of rotations into one abridged post. But, hey, so goes the life of the dietetic intern.

Week 13: Cardiology

Cardiology was my only 1 week rotation – and man, it went by SO FAST! I do feel like the length of the rotation was appropriate, however, given the patient population. During this rotation, most of the patients I saw were status post heart attacks, CABG procedures (stands for Coronary Artery Bypass Graft, and is pronounced like the vegetable – “cabbage”), or admitted with Congestive Heart Failure (often referred to as CHF). Working in a hospital as a clinical dietetic intern for 13 weeks prior to this, I had already been exposed to most of these conditions, and I don’t feel that having a very long cardiology rotation would have enhanced my experience dramatically. I basically gained more practice giving heart healthy diet and CHF educations, which I welcome more of! My one complaint for this rotation is that it was my only week working on a unit at a different campus than my other weeks, and it was a bit challenging to get used to the different buildings, and a new set of operations in such a short amount of time.

Because the heart healthy diet is the primary need on cardiology units, I’ve created a separate post to provide an overview of the guidelines. You can view the post HERE! The rotation really inspired me to spread the word about heart healthy diets, and catching signs of heart failure, because death related to heart disease is typically so preventable.

If you are in dietetics, I welcome your feedback. And if you are just interested in learning about the diet for your own benefit or that of a loved one, please leave a comment and let me know if you found the information helpful. Questions and comments are ALWAYS WELCOME!

And after Cardiology, it was on to Critical Care!

Weeks 14-15: Critical Care

This rotation was INTENSE, mostly consisting of recommending nutrition support options. The majority of the patients I saw were NPO, so taking in no nutrition by mouth. I had the opportunity the learn about the current nutrition support guidelines according to ASPEN and the Academy of Nutrition and Dietetics, and gained a clearer understanding of what makes each formula unique and appropriate for various individual conditions.

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Lot of calculations and lab values in Critical Care…

Not only was my critical care rotation interesting, but I also felt like a very strong component of every patient’s care team. I attended daily rounds on the ICU floor in which each critical patient was discussed, and the opinion of the dietitian was typically obtained, and highly regarded – usually my recs would be implemented immediately without hesitation! In previous clinical rotations, I recall experiencing frustration when having to recommend the same diet changes multiple times, seeing no orders placed. In the ICU, I felt capable of making a difference in the care of patients, and felt truly empowered as a proponent of good nutrition, particularly as I got to watch the transformation some patients took once appropriate nutrition recommendations were implemented.

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You fellow interns and RDs feel me??

Week 16-17: BREAK!

After Critical Care, I was lucky enough to have a 2 week long break. I spent a nice chunk of that time catching up on clinical readings and assignments, but I certainly got to have some fun as well…

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Went camping…

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…in Morro Bay, California…

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…with my best friends in the entire world (my SISTERS and parents)…

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…who walked all over town with me when I just had to have some Cioppino (it was SO worth it)…

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…We even got to have a little camera fun…

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…and got so many beautiful sunsets…

Then I got to welcome 2014 with my sister and brother from other mothers in Seattle, WA and Vancouver, BC:

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…where I got to see Captain Kirk’s Chair at the EMP Museum

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…climb atop this Space Needle…

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…with THESE two…

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…clean ourselves up for a New Years Eve celebration…

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…and I even found my name in LIGHTS!

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And of course, once returning to San Francisco (<3), had plenty of time left over for tasty coffee, a farmer’s market…

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 …and a little at-home yoga :).

And it’s a seriously good thing I got so much me time over these two weeks. I was definitely going to need it entering my eating disorders rotation…

Week 18-19: Clinical Elective – Eating Disorders

In a happy twist of fate, on my very first day of interning, my CNM offered my fellow intern and me 2 options for our clinical elective: eating disorders, or NICU. I immediately jumped at the opportunity to claim EDs – although I wish I could have experienced both areas of specialty, I’m sure no one is surprised by my choice.

My elective week brought up a whirlwind of emotion, both positive and negative. But the greatest thing I took from these two weeks was that I felt right at home. It was incredible to be reassured that ED treatment and recovery is the field I am meant to be in, because of my passion, my skills, and my own personal struggle. I feel blessed to have found this so early on in my career, and am so glad to see I still feel the way I did at the start of this journey.

Most of the week involved a lot of shadowing. Given the high specialization and touchy nature of this field, at the start of my rotation it was unclear whether I would have the opportunity to counsel one on one. However, after a few days of sitting in on sessions and observation of groups, in addition to spending time note writing and reviewing the past medical histories of the patients, I was able to conduct supervised one on one sessions with a number of people. This experience was anxiety-inducing, incredibly exciting, and limitlessly humbling. I was reminded of the love I have for this field, and was also reminded that I am quite good at it naturally! But I also saw how much I do have left to learn, and look forward to the career ahead of me.

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^This is what note taking looks like in an eating disorders rotation…

Weeks 20-21: Staff Relief – FINAL WEEKS IN CLINICAL!

Staff relief… What to say about staff relief. Well, I’m sure I grew from it, and I can say that. There were also a lot of tears coupled with self-doubt and feelings of inadequacy. Not to get all negative Nan on ya, but this experience is what it is, and I’m here to share it with you.

I must say, now that staff relief is behind me, I could not be more appreciative of those two weeks. I think it is so important to have them under your belt before entering the field as a clinical dietitian. But it was TOUGH!

For those of you who are unfamiliar with the term, staff relief is the rotation that usually comes at the end of your clinical rotations. During staff relief weeks, the intern is to act as dietitian, covering a unit on his or her own. It’s really the first taste you get of working independently as a clinical dietitian.

After discussing my staff relief rotation with my internship director, I learned that my experience was atypical. This may be one of the challenges of being in a distance program – my director is unaware of how things are going unless I share the information with her. During staff relief, most interns will cover 1 unit – ICU, Oncology, Med/Surg, etc (per my director, interns typically cover Med/Surg floors). During this rotation for me, things were organized a bit differently. The dietitians from each floor would assign me about 2 patients, totaling up to about 6-8 patients per day. I found that the most challenging part of this was having to switch mental gears from oncology to critical care to cardiac to CVAs so many times per day. I feel this brought down my level of efficiency, and made it challenging for me to do a quality job while also seeing the appropriate patient load each day. This impacted my confidence significantly, and I really had moments when I doubted whether I have what it takes to be successful in the field of clinical dietetics.

The good news is, once I spoke with my director (2 weeks AFTER completing this rotation), she assured me that my experience was not typical, and that seeing so many different types of patients each day in fact WAS quite challenging. I was so relieved to hear this, and felt I could reassure myself that staff relief did not indicate that I had made a catastrophic decision in choosing to become an RD.

Let it be a lesson to me – to give myself a BREAK, and not jump to thoughts of failure so immediately at the first sign of struggle.

So, that’s a wrap for my clinical rotations! I cannot believe that one of the biggest challenges in my path toward my RD is behind me. My next post will talk about my experiences working in long term care and community nutrition. Please check back for updates soon!

And all you DI hopefuls applying through DICAS right now, you are in my thoughts as programs sift through your applications. Next will be interviews for many of you! Remember: smile, stay calm, and be yourself – you’ll do great :).

Stay happy :).

Week 7-12: Renal, GI Surgery, Oncology

This post may be a little extra long, as I’ve neglected to update in over 5 weeks. So get ready, as I tell you all about my experiences in renal and antepartum, GI surgery, and oncology.

First up… RENAL/ANTEPARTUM

This rotation was marked for me by a significant amount of personal difficulties. During the two weeks I spent on the hospital’s Renal and Antepartum floors, I decided to embark upon a journey into sobriety due to circumstances unrelated. Days after I made this life-altering decision, my boyfriend of three years and I decided it was time to end our relationship. I may talk more about each of these struggles in future blog posts on my main homepage, but am trying to keep this portion of the site dietetics-focused. I just want to mention it to remind us that life goes on while we’re going through this internship–that was something I think I had forgotten until something happened that seemed to cause the ground beneath me to shake, and I was looking at a life I didn’t recognize anymore.

Despite this change in lifestyle and relationship status, with puffy eyes, and way too many feelings to filter through all at once, I did the best I could to keep my head in the game, and my eye on the prize. I allowed myself a few days of tears (ok, maybe a little more than a few days), but really tried to remember why it is that I am here–to fulfill the dream I’ve been working toward for nearly 7 years now. I had to keep reminding myself–I’M ALMOST A REGISTERED DIETITIAN!

During these weeks of my rotation, I was under the preceptorship of the clinical dietitian who covers the renal/dialysis floor, as well as the antepartum floor. One of the things I’ve noted as a challenge has been the fact that I may be in a rotation entitled “renal,” but given that we are in a real-world setting, it doesn’t necessarily mean I will see a single renal patient that week. It all depends on who gets sick when, and what overall census looks like. So in this rotation, I learned to go with the flow a little more than usual, and had to remember that I may not meet every single competency outlined for me exactly on schedule.

Some of you readers may be well-versed in renal health. But in case you are in the (I’m assuming large) pool of people who are not, let me define dialysis briefly for you. Let’s start by discussing the function of a couple of our primary detoxifying organs: the kidneys. When the kidneys are functioning normally, they filter the blood for excess fluids, vitamins, minerals, and toxins. In people with Chronic Kidney Disease (CKD), the rate at which their kidneys filter out these items is much lower. In the clinical world, we look at a lab value called Glomerular Filtration Rate (GFR), which is basically a big scary word that indicates the rate at which the kidneys are filtering–and indicator of kidney function. In people with compromised kidney function, GFR is usually low. At Stage 5 CKD, the most advanced stage, GFR is typically lower than 15, which indicates probable kidney failure, and a likely need for dialysis. Dialysis is a process by which this filtration of fluids and waste from the blood can be done in those with compromised kidney function. Dialysis patients are hooked up to a machine for a few hours, usually multiple days per week (most patients I saw were 3 days per week), and the machine does the work of which the kidneys are not capable. Dialysis is not only used in Stage 5 CKD patients–it can be utilized earlier on in CKD, and is sometimes used in episodes of acute renal failure or acute kidney injury as well. Patients on dialysis may often get away with a slightly more liberalized diet–if you think about it, it’s because they have external kidneys helping them out! However, this doesn’t mean these individuals should go out and enjoy all the sodium, potassium, and phosphorus they can stomach. If they were to do this, dialysis can end up being a much more painful process than it needs to be, as this can lead to some serious discomfort.

I did manage to see a fair amount of patients with kidney injury and CKD during my second week in this rotation. It was a great way to become more familiarized with the restrictions of a renal diet, which can often be complex. So many nutrients are filtered by the kidneys, so when they are not functioning properly, it can mean some heavy restrictions are in place. Sodium, potassium, and phosphorus are in so many food items. And given that many patients with renal disease tend to have co-morbidities (to which the kidney disease is often secondary), diets for these individuals can become highly restrictive, and it can be difficult to meet needs. It’s moments like this that supplements like Nepro with Carb Steady come in handy!

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Our other unit, antepartum, housed expectant mothers who were hospitalized, often due to complications of pregnancy (i.e. these women were NOT in labor). The role of the dietitian on this floor is primarily to work with patients who have Gestational Diabetes (often referred to as GDM), and were a part of the Sweet Success program. Sweet Success is a program that is part of the California Department of Public Health‘s diabetes and pregnancy program. It provides resources to expectant mothers with GDM, as well as healthcare professionals to increase the likelihood of healthy pregnancy outcomes.  GDM is a tricky type of diabetes that occurs during pregnancy. The mother does not remain diabetic after delivery, but it places her at higher risk for developing Type 2 Diabetes later in life. *If you want to know a little more about diabetes, check out my post from my Endocrine rotation, or my Diabetes month video*

The GDM diet is highly specialized as well. Although the mechanism is not entirely understood, it is well-supported that certain foods and food combinations cause particularly high blood sugar levels in these patients. The primary restrictions are: no fruit OR dairy in the morning, and no fruit and dairy TOGETHER at any meal. As you might imagine, in a hospital setting, the GDM menu can become tiresome, especially at breakfast. Unfortunately, many of the items we have become accustomed to at breakfast time are carbohydrate-dense. And dairy and fruit tend to be thought of as sensible breakfast choices! I often saw frustration coming both from the patients, and my preceptor, in trying to work out appropriate menu choices, and began to feel the frustration myself. If I had this rotation to do over again (perhaps with a little more time), I think a great project would be to figure out some GDM-friendly breakfast options that would not add too much to the workload of kitchen staff—maybe something to think about for you FUTURE DIETETIC INTERNS??

This rotation did come with a side project, though! I spent one day down in the kitchen observing one more tray line (back to the refrigerated room!). I observed as the Sweet Success trays were plated to ensure servings of carbohydrates and starches were done accurately. Very riveting stuff here, folks.

And the results…..? PASS! Maybe it was just because I was watching, but I will express how impressed I am with this sweetly successful audit. Go Alta Bates kitchen staff!

Moving right along to my next rotation… GI SURGERY!

During these next two weeks, I learned far more about the gastrointestinal (GI) tract and its various potential complications than I thought possible. And I must say, I found the information interesting. I may not want to study colostomies over dinner, but the intricacies of the GI tract are, to quote my favorite Vulcan, FASCINATING. Although I was a bit sad when I learned I would not be observing an actual GI surgery, I did have the opportunity to spend part of a day with the hospital’s wound care and ostomy nurse. I observed as she did an education with a patient who recently had a part of his colon removed, and would be spending the next 6 or so months with an ostomy bag. I will explain what an ostomy bag is briefly here so you don’t have to Google it (please, do NOT Google it).

FAIR WARNING: The following may not be for the weak-stomached… If poop makes you squeamish, skip ahead 1 paragraph.

An ostomy bag is used when a person has undergone a GI surgery that interrupts that pathway of digestion. Essentially, feces is not able to takes its usual route, so a stoma (or hole, basically) is created in the abdomen. A bag is attached to the stoma, and collects the waste. A procedure like this is often done in patients with different types of cancers of the lower GI, but has other uses as well. I met with one patient who had this procedure done to facilitate the healing of a wound near his coccyx, rerouting his digestive process to avoid putting extra stress on the area that required healing. Again… FASCINATING.

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Just maybe not through the same route…

IF YOU DECIDED TO SKIP THAT, you may rejoin us here :).

After two weeks in GI, I had the privilege of moving on to ONCOLOGY.

Although this rotation had some emotional ties for me (probably for most… cancer is sad), I think I enjoyed it the most out of all rotations so far. Three days a week in this rotation, I was working on the hospital’s inpatient oncology unit. Many people on this floor were undergoing chemotherapy. Some were newly diagnosed with poor prognosis, and were not receiving treatment, but being “made comfortable”. Others were being prepared for a surgery that may or may not be curative. The other two days out of the week I was at the outpatient Radiation Oncology department, working with individuals who would visit the center for outpatient radiation.

Oncology and nutrition seem to go hand in hand. There is the prevention side, which I one day might really love to be a part of, in which an overall healthy diet and lifestyle is beyond important. And then there is the treatment side. When a person is undergoing cancer therapy (or multiple therapies, in  many cases), so much is beyond their control. But nutrition is something that, while challenging to maintain in the face of nausea, dry mouth, and taste alterations, is an area in which we can try endless different combinations to see what works, and what doesn’t. As a nutrition professional, in the oncology department, I actually felt empowered to make a difference. I found my response to this interesting, because I really didn’t expect it! Who would have guessed that in the face of this wretched disease, where so much is beyond the patient’s and clinician’s control, that this is where a dietitian might feel in control, and able to make a difference?

The world of radiation was also an incredible experience, and I’m so grateful to have had it. Firstly, there is something about the energy in an outpatient facility that I think I like a bit more than inpatient. Of course, there is the lovely factor of NO WEEKEND SHIFTS. But there is a different kind of calm that seems to permeate outpatient facilities that I have visited so far.

During my Oncology rotation, I also presented my CASE STUDY! What a project… My case study patient was one with pancreatitis. I will be posting my slides and a recording of my presentation to my online portfolio if you are interested!

After Oncology, it was home for what I feel was a well-deserved Thanksgiving break. I decided to take a solo scenic route road trip from San Francisco to Los Angeles, and brought my camera along for the ride:

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Most AMAZING Acai Bowl from Cafe Brazil in Santa Cruz. Seriously. Go there.

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Rocky Canyon Bridge, just before Bixby.

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Made it home, just in time for a shameless selfie.

The solitude and quality time with my good ol’ trusty Canon is exactly what I needed. Oh, not to mention the family time that followed:

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True love.

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Probably the first time we’ve ALL (dog included) successfully gotten together for a family portrait. Go Finkelsteins!

As of Friday I have finished my Cardiology rotation as well! But so as not to lengthen this post too much, I will save it for my next update. Tomorrow begins my Critical Care rotation in the ICU!

I hope that you all had a wonderful Thanksgiving, and were able to share it with loved ones.

Remember to nourish yourself this week! ❤ TNS

Diabetes Awareness Month!

It’s Novemeber! And this month is about more than just who can grow the sickest mustache for Prostate Cancer Awareness… It’s also Diabetes Awareness Month!!

Inspired by this video, I decided to come back at ya’ll with my first video in about 6 months to discuss a truly important topic. In this week’s (or month’s… season’s…) video, I’ve discussed the basics of both Type 1 and Type 2 Diabetes — the two major types–with some information about disease prevention and management through diet and lifestyle.

If you already have diabetes, or are/may be pre-diabetic, speak with your healthcare team about the best course of action for you, and about proper diet plans in addition to medications and/or insulin.

Please contact me at thenourishedsoulblog@gmail.com with ANY questions, or leave a comment below!

Now go move!

P.S. I am a bit more “glow-y” in today’s video than usual. Darn bay windows… Please bare with it! Or hide my face… it doesn’t matter. Just listen! Enjoy.

Weeks 4-6: Clinical Management and General Medicine

As is likely evidenced by my online absence—it has been a crazy few weeks! So, here’s what I’ve been up to:

Patient Services/Clinical Nutrition Management Rotation

            I learned a serious amount during this 1 week long, jam-packed rotation. Biggest lesson: I don’t believe management is in my near future. The Morrison-Chartwells internship has a strong focus in management, as does the overarching Compass Group of which Morrison and Chartwells are a part. So that’s why I’ve been lucky enough to have the opportunity to experience RD supervisory roles prior to even becoming a registered dietitian. My primary preceptor for this rotation was a highly-qualified RD, MSc, PhD who it seems loves the management side of clinical nutrition. I was able to see into the world of policies and procedures, interdisciplinary meetings, and personnel management. I have had exposure to this in my experience as Dietary Director of my little 56-bed skilled nursing facility before my time at UCSF Medical Center. But the observation and hands-on days I had at Alta Bates in this rotation were on a much larger scale, as a hospital with greater than 500 beds, working with multiple highly-educated people in various disciplines, and helping to oversee a team of brilliant clinical dietitians.

            As valuable as this experience has been, I will reiterate: I don’t see clinical management as my path at this time.  But hey, that’s the beauty of getting to participate in supervised practice before becoming a dietitian, right??

            The Pros: Having the opportunity to work with such qualified people was certainly inspiring.  I also got to meet people in different departments (i.e. pharmacy, human resources, physicians, etc), and also the movers and shakers within various areas of the Food and Nutrition department (i.e. foodservice directors, patient services managers, and the cooks, diet aids, and nutrition assistants that make the entire operation go). I really enjoyed the time getting to know all of these people. I have always felt it very beneficial to gain knowledge of positions other than your own to really understand why things are done the way they are, giving us the ability to do our jobs better (and maybe with less attitude). So there are the positives!

            The Cons: I missed patient care while in this rotation. Management has a major impact on this, of course. But direct patient care is just not something managers get to do much of—it’s one of the things they’re often forced to delegate in such a large operation. In fact, even as a SNF dietary manager, I found that the tasks I had to do relating to patient care fell to the back burner, as they were often the easiest jobs to delegate, and other issues such as food orders and immediately pressing scheduling problems would arise that needed to be dealt with. I also felt my clinical brain was not being exercised as I had hoped. Having a strong clinical background of course allows a clinical manager to do their job with an appropriate knowledge level, but… I wanted to do a dang TPN calculation! …Whoa, never thought I’d say that.

I will admit that this rotation tickled a nerve that begged that horrifying question, not once but a few times: “Am I in the right field? Have I made a mistake?”

Although the question was asked, I think in my little adequately-nourished heart knew this was just a challenging start to an incredible experience. I love what I know so far from the world of nutrition and dietetics, and I don’t feel it is possible that I could ever give it all up. This rotation reminded me that every field—no matter how ideal—will have its moments that even the most die-hard avengers will dread. For me, it appears one of those moments will involve chart audits and patient satisfaction surveys (ick).

Fortunately, the next few weeks reminded me why I DO love nutrition…

On to General Medicine—I finally get to play DIETITIAN!

 

After 3 weeks of rotations that felt entirely different from my expectations, with days of doubt and questions, I finally got to participate in what I feel I can fairly deem SUPERVISED PRACTICE. I arrived at Alta Bates’ Herrick Campus on the outskirts of Downtown Berkeley for my first day of my General Medicine rotation. This campus is primarily a psychiatric hospital with a residential, IOP (intensive outpatient), and PHP (partial hospitalization) eating disorder treatment program. One lone unit up on floor #5 houses the acute rehab department, and this is where I spent my two weeks in Gen Med.

            I saw a variety of types of patients during this time, although the majority were admitted with a stroke diagnosis. Many of these patients, secondary to their strokes (or CVAs – ‘cerebrovascular accidents’), were experiencing difficulty swallowing, otherwise known as dysphagia, which of course puts them at risk for malnutrition. Swallowing difficulty usually leads to patients being placed on diets that range from pureed to ground to chopped, and may be put on thickened liquids to avoid risk of aspiration or choking. Because these diets can cause food to be unappealing, and stroke patients may already have decreased appetite for various reasons, intake can decrease significantly. In the acute rehab unit, the neuropsychologists, speech therapists, dietitians, along with many other disciplines, play major roles in patient recovery, and it was empowering to be a part of a team with such capable hands.

            In addition to our stroke patients, we saw people with an array of complications from improper nutrition. Sometimes coupled with a CVA, patients admitted to this unit often presented with diabetes, heart disease or congestive heart failure, renal disease, and so many more.

Primary Diets Involved in This Rotation:

Carbohydrate Controlled

Renal (Limiting Sodium, Potassium, Phosphorus)

Fluid Restrictions

Modified Texture/Liquid Consistencies

*Many patients were on combinations of these diets—not just one restriction

 

The most impactful situations to me involved patients who had lived with uncontrolled diabetes for years, and had gotten to the point of exhibiting all those dreadful complications that we aimed to warn people against during my first rotation in the Diabetes Center. Meeting with patients who were on hemodialysis multiple times each week for their chronic kidney disease, who sat in front of me with BOTH legs amputated due to uncontrolled blood glucose levels, yet persisted to drive home their points on why their diets should be liberalized was truly eye-opening. What these experiences taught me is that no matter how knowledgeable a practitioner is, a dietitian (or doctor, or nurse, or therapist, etc.) CANNOT create motivation within another person. That truly has to come from within, and sometimes even a bilateral amputation won’t do the trick. So we just have to wait and see if something else does, while in the meantime giving our patients the best in-hospital nutrition care possible, and providing them with any education they will accept.

            I’m now moving on from Herrick, and heading to Ashby Campus. I will be returning to Herrick in January for my Eating Disorders elective rotation—can’t wait!

My time in General Medicine has given me a strong basis to head into my rotations to come, as I learn about some more specialized fields. Renal and Labor/Delivery is next! Stay tuned :).