diabetes

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.

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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 :).

Week 2/3: Outpatient Begins in an Endocrine Setting

Well, what a few weeks it’s been. I have learned a lot already–about outpatient counseling, carb counting, insulin, and even a bit about myself. Let’s start with my first week of rotations:

Monday: Orienting. Chaotic. Most of the day involved explanations, introductions to supervisors and systems, and a fair amount of confusion on everyone’s part. The day concluded with a brief meeting with the RN who supervises the Diabetes Center–where I would be completing my Endocrine/Diabetes rotation, and 1 week of outpatient.

Tuesday: 9 hour day. Got to meet my RD preceptor who I knew I’d get along with famously (I rarely meet an RD I don’t like…). I got to sit in on her 1:1 appointments, and observed a “Diabetes 101” 4 part class taught by the RD and another clinical team member. This class was the fourth of a four part series, and it was great to see the participants graduate at the end of the evening with confidence in their ability to own and manage their disease!

But finally sitting at home around 10pm, I found myself seriously questioning whether I have what it takes to get through this, and hoping for a better tomorrow.

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Hashtag Overwhelmed.

The day was challenging for a number of reasons, but a major hurdle I’m running into is the lack of understanding it seems people in other disciplines have as it relates to dietitians, dietetic interns, and our level of competency. Although I have an assignment which involves me teaching a nutrition education class (for which tonight would have been a PERFECT opportunity), the RN supervisor overseeing me stated she did not feel comfortable allowing me to teach, and that she felt I was there more for observation than participation/practice. I can’t blame her–she’s just not been told what a dietetic intern does, and that we are here to get hours in SUPERVISED PRACTICE. It has become frustrating on a number of levels, but I imagine it’s a taste of what some Registered Dietitians face on a daily basis. I do hope our reputation in the medical field is improving–we’ve worked hard to get here!

Wednesday: What an improvement! This day I got to have some actual patient interaction, and felt that I did relatively well. I worked with the Physician’s Assistant/Certified Diabetes Educator who does more of the medical side of diabetes education. I got to act as a true “RD-in-training” whenever her patients had a nutrition-related question. I felt needed, competent, and believed-in. My mood only started to decline once I realized how much work there was to do, and how in deep I really am.

Thursday: Similar to Tuesday, I got to mainly shadow the RD. I wasn’t able to jump in and do any 1:1 counseling on my own due to the supervisor’s wishes. But we found ways for the RD to assess my abilities, and I am meeting my competencies for the rotation.

Friday: For the final day of the week, I took a break from the Diabetes Center and reported to the main hospital across the street: Alta Bates Summit Medical Center – Ashby Campus in Berkeley. I met briefly first thing in the morning with the Food Service Director who greeted me with a bubbly sense of pride that I couldn’t have needed any more at that point. We discussed some basic logistics–what I needed to know to survive the day. She then sent me off to the diet office where I met the nutrition assistants. Throughout the day, I shadowed, asked questions, and saw the world of Alta Bates Med Center through their eyes. I got to meet the team of clinical dietitians at this campus, as well, who will be leading me through much of my clinical rotation.

The last part of my day went from 2pm-4pm, and gave me chills… LITERALLY! I observed and assisted in tray line, which lasts about 2 full hours, and actually takes place in a REFRIGERATOR. Temps in this room are very close to 40 degrees Fahrenheit. My hospital works on a cook-chill system: the food is prepared then frozen at a main kitchen, plated in tray line, and then sent off to wherever it will be served (if trays are going to a campus away from the main kitchen), and reheated immediately before serving. It’s a system I’ve learned about many times, but have never seen in live action.

Here is a flow chart that outlines the steps of the cook-chill system in comparison to a more common cook-serve system (Original link to diagram found here).

                                                                                                 Cook-Chill [Yellow] v

Production flow charts for school lunch boxes

^ Cook-Serve [Green]

So the tray line takes place in a cold environment so that there is no chance for food temps to reach the danger zone: 40-140 degrees–the window in which bacteria thrives. This tray line ends up providing meals for patients at the campus I’m primarily working at, in addition to the campus nearby which houses our psychiatric and residential eating disorder treatment programs–they produce HUNDREDS of trays! It was really something to witness… These hours served as a highly valuable learning experience. I’ve always found that when employees thoroughly understand the inter-workings of an entire SYSTEM, and not necessarily just the requirements of THEIR jobs, it allows all employees to perform their jobs at a higher level–even if all of the positions do not seem to cross paths directly.

After that week, I was beyond ready for a nice long weekend. Saturday I got to spend connecting to my Jewish heritage, as I participated in a Yom Kippur fast. Once we hit sundown, it was bagels and lox until our bellies stretched to capacity  (and beyond), and some of us even may have had to undo a top button…

Sunday was a bit more fun–got to attend a concert we had been looking forward to for months (The Slackers, for any ska fans out there), and spent the day in beautiful Santa Cruz.

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The instant serenity-inducing beaches of Santa Cruz — No filters needed here.

image (1) We rode that pirate ship ride that goes back and forth at the Boardwalk… It remains terrifying, in case you weren’t sure.

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The Slackers put on a seriously entertaining show, per usual.

The week began again far too quickly, but I jumped in with all the enthusiasm and vigor I could muster. My second week in Endocrine allowed me to hone some of the skills I was merely introduced to the week prior. Week 2 felt more hands on, as I felt more comfortable providing input during patient sessions, and knew which questions to ask both patients and practitioners. I also got to write my first very own chart note! I had the opportunity to attend another Tuesday night diabetes education class–this week was part 1 of 4, so it had a different feel to it. These participants were likely newly diagnosed, or just newly motivated. A lot of emotions filled the room that night–from excitement and enthusiasm, to denial, to fear, to confusion and unknowing. It was refreshing to realize I wasn’t alone in having those feelings ;-). By the end of the class, it was great to say goodbye while hearing the joy in the voices of some as they said “I’ll see you next week.”

Friday involved another diet office training. I got to meet a few more team members, and learned more about the management side as I shadowed the Patient Services Manager for the day.

The week wrapped up nicely, and I embarked upon the social weekend I had planned for myself! Met some great new people, and attended the last Movie in Dolores Park of the year before the weather turns cold (because it’s been just a blazingly hot summer here in San Francisco–oh wait, no it hasn’t).

I am now beginning week 4 of my internship: Patient Services and Clinical Nutrition Management. Check back at the end of this week to see how it shapes up!

In the meantime, be kind to yourself–I know I’ll be trying :).

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*Note: Most of my pictures within posts at this time are not necessarily going to be dietetics-related, as I am waiting on permission to use pictures I take at my rotation sites on my blog. So enjoy my personals! And check back–hopefully I can utilize the professional ones!