education

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

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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).

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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!

REPOST – CALLING ALL DI APPLICANTS: It WILL All Be OK.

And here we are again. One full year + 1 week after the post below, wishing we could just sleep through the next 24 hours, and wake up to the match awaiting us in D&D at 6pm Central time tomorrow. I feel the need to re-post this from last year’s match-weekend, as it STILL APPLIES. Last year, I did not match. And while I used my time wisely this year, the possibility of a repeat experience is there. So here is a reminder for me, for you, for anyone out there who joins me in this wait:

 

**I’d love to hear how all you fellow applicants are taking care of yourselves today and tomorrow to keep from going batty. Please share your tactics in the comments!**

From April 1, 2012 @ 6:27pm:

Anxiously awaiting mid-day tomorrow to learn the results of the dietetic internship match, we applicants are likely in agony. Each of us has been anticipating this day since we clicked “submit” for our final application on February 15. Or, if you are like me, you have been waiting for this day for the last three or so years.

Now is the time for us to truly take in the fact that the results of tomorrow’s match in no way reflect our competencies as future dietitians. We are all qualified, and well-rounded. To have put in the work to apply to DIs shows our dedication and our drive. Of course we are all viable competitors; if we were not, this process would not be nearly as grueling as the past 4+ months have been. The nature of this process is COMPETITIVE. With a 50% acceptance rate (when we’re lucky), we must not forget that sometimes, this path is not ours just yet. The competitive nature of the process itself should make us feel proud to be contenders.

As I have been telling my loved ones who have inquired about the rate at which my nerves are doing cartwheels in my belly/shoulders/brain/duodenum, I know I will become an RD. It is simply a matter of when. Maybe this process will take off like a speeding bullet tomorrow. Or maybe tomorrow will be the start of a longer, but equally fulfilling (perhaps more so) path.

No matter what happens tomorrow when we read our crassly delivered results off of D&D Digital, I think one thing is so important to remember: Match, or no match, we will ALL BE FINE. Some will be matched, many will not, but one thing is certain: WE, as people, are OK, and will continue to be GREAT. Moping, crying, and racing, unpleasant thoughts may occur—allow yourself these thoughts. Accept what becomes your reality, and move on. Don’t give up hope, just know that right now, for whatever reason gives you comfort, you are just meant to be somewhere else.

What will happen will happen, and we will ALL BE FINE. Que sera, sera.