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!
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.
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:
Most AMAZING Acai Bowl from Cafe Brazil in Santa Cruz. Seriously. Go there.
Rocky Canyon Bridge, just before Bixby.
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:
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