Mangalista Mania

Several months ago I agreed to purchase a pig (I don't think it was the pig pictured above) from a high school friend, Kylan Hoover. Six months before Kylan and I had gone for lunch together, while catching up, Kylan casually mentioned that he was interested in returning to pig farming (He had raised pigs for the fair in high school). I had just been reading on Michael Ruhlman's blog about a pig-purveyor in Washington who was looking for a northern California outlet for his prized Mangalista. One thing lead to another and Kylan was the proud daddy of more than 50 pigs in less than a month. Given the introduction I feel a connection to his "herd" of piggies.

When given the opportunity I had to have one. Some girls have to call their fiances and say "I went a little crazy and bought another pair of shoes", I had to say "I kinda just bought a pig... with your checkbook." Lucky for me Andy (and my mom) really like bacon. Even a small pig yields far more pork than two can reasonably eat so I solicited friends to purchases "shares" of our new friend.

I have never bought a whole animal for consumption before (chicken's don't count). I didn't know the pertinent questions to ask:
Q: How will the Mangalista go from living to dining?
A: The swine along with nine other friends were transported in a horse trailer from their home in the Livermore Valley to a small family owned slaughterhouse in Modesto on a Monday. Where they met their end quickly and humanely. The whole hogs were transferred in a refrigerated truck to Star Meats in Berkeley where my pig "hung" for several days. Hanging is necessary to allow natural chemical reactions to occur taking the meat from icky to amazing. Kylan left directions for the cutting and on Friday morning the pork was cut. Friday afternoon we picked up many neat brown packages.

The other pigs went on to the French Laundry where they were processed for curing and aging. They will make a prominent appearance early next year on the menu.

Q: How many pounds of meat will the piggy yield?
A: When all is said and done I still don't know. By conventional standards my pig was small weighing just shy of 200 pounds at the end. I weighed most of the individual cuts in order to fairly divide among shareholders. However, I did not weigh the head, heart, kidney's, liver, lard or intestinal bits. Some of the poundage is lost during butchering I think its safe to safe in the end I had over 150 pounds of pork.

Q: What happens to the head, heart, kidney's, liver, lard and intestinal bits?
A: I kept and rendered the lard myself.
I met my limit at "processing" the other offal so I arranged a trade with Hank Shaw. Who made excellent use of the other nasty bits and publicized Kylan's business a bit on his blog Hunter Angler Gardener Cook.

Q: How do you fairly divide the pork among shareholder's?
A: We laid all the neat brown packages out on a table in the garage. We took out several "odd" pieces including the pork shoulder that I roasted for the party. We weighed the pieces and with Kylan's help we just started making "equal" piles. On the day of distribution I used my own share to swap with people who wanted different cuts. It just worked itself out.

The list of questions goes on and on.
Needless to say most of us (including me) don't really know how our dinner starts.

Let me tell you this dinner was damn good even knowing a little bit more about where it came from.


Photos courtesy of Andy Bliss - More photos of the pig party.

Daily Grind - Food Service Managment

Compared to my almost grueling 10-week clinical rotation, my 4-weeks of Food Service has gone by lightning fast. I barely have blinked an eye and I am done.

Once again I was assigned to a hospital within the Texas Medical Center, that's where the similarities between the experiences stop. Unlike my clinical rotation: I arrived at 7:30 am and was almost always gone eight hours later at 4:30 pm; I saw patients only in the halls of the hospital, I don't think I uttered more than ten words to one; I spent a lot of time in the basement (where most hospital kitchen's are located); I had more than enough time to complete the tasks assigned to me; Everyone was really, really nice, all the time.

I wish I had a quarter for every time I have heard: "I didn't get a degree (or two or three) to work tray line", "I hate to cook", "I don't do food service". Seriously, the way many dietitians talk you would think nutrition and food were completely unrelated. Most dietitian despise the words "food service". So, I hate to admit it... I kinda of like it. Although industrious employees who take great pride in their attention to detail, food service doesn't take its self quite so seriously. Your fellow employees come from a greater slice of life. Not everyone has a college diploma (or even a high school diploma); its a little less idealistic, a little more r-e-a-l.

Typical tasks performed during this rotation:
- A lengthy "Patient Services" check-list to get familiarized with all the jobs and tasks required to get meals to patients.
- Audits of: Patient identification and proper hand washing among food service employees (No need to worry: Everyone appropriately identifies patients, everyone washes their hands), the proper use of formula order form among physicians, and kitchen inspections of the hospital and food court kitchens
- Documentation of food service related charges in a doctor's lounges of a newly opened unit of the hospital
- Development of independent learning activities for food service employees who missed customer service training
- Development of a bulletin board marketing a customer service program to employee's
- Data collection and presentation of clinical dietitian monthly productivity
- Analysis and recommendation of provision for emergency food supplies (MRE's v. recognizable, microwavable product).
- Development of tool to track quarterly changes in food cost

Yes, some of this work was tedious. However, I was exposed to the breadth of tasks required in food service management. My days also could not have contrasted the relative sameness of the days of a clinical dietitian more.

Twilight

There is something completely absorbing about these books.

They are the absolute epitome of a fairy tale and the
sickening reality of adolescence woven together.
Highly recommended

Hurricane Ike

Hi all!
Thanks so much to all of you who e-mailed, called, texted or just thought about my safety over the past 24 hours.

I am happy to report that I have survived my first (and hopefully my last) hurricane unscathed. Many others in the gulf cannot say the same, I feel very lucky. Hurricane Ike came through over night, the real action lasted about 5 hours. Jenny (my roommate) and I dragged a mattress and pillows into the hallway and slept there. It was loud and a little scary but all-in-all okay. Our power was out for about 6-hours but came back on this morning (Most people in the area are not expected to regain power for a few days.) We are LUCKY.

I have posted a few photos at http://picasaweb.google.com/tjgirl/HURRICANEIKE#. My entire neighborhood has debris and trees down all over. Most of the street lights are out. Many of the street signs have been toppled. It just generally looks tattered. People are out and about cleaning up. Most in good spirits. You can hear generators buzzing, people are BBQ-ing. While it NO way feels like a block party, people openly express their gratitude for their personal safety and property. I think everyone's just glad its over.

I expect to go back to work at the medical center Monday or Tuesday.

Hope each of you are safe , warm and dry.

Be in touch.

Always,
~Taryn

Daily Grind - Clinical

In some ways I can hardly believe that I am already 1/2 way through my Clinical rotation. In other ways if feels like it should be long over. The Clinical aspect of the internship is the longest and most intense of the 5-rotations. It is a 10-week crash course in not only the various disease states and how they relate to nutritional status but also the mechanics of working within a hospital.

It is the practical application of everything you have learned in school
AND everything they don't teach you.

I am at a large, prestigious teaching hospital. It is ranked as one of the best hospitals in the country. Inarguably, it would be next to impossible to get a better experience somewhere else. However, it does have a reputation for being tough on interns. Within a matter of weeks we are expected to learn the lay-out of the hospital (a sprawling 5-building complex with up-teen elevators), a computer charting system, a food service set-up, the subtitles of relating to Dr's, nurses, and other essential personnel, AND see and document on 8-10 patients a day. We work under a different dietitian each week, whom each cover very different floors. Every day, every week is different than the one before. With the level of expectation building the longer we are there.

I have had the opportunity to work the following floors/specialties: Cancer, General Medicine, Cystic Fibrosis, Neuro-ICU, Neuro-stepdown (strokes and other brain injuries), Post-Gastrointestinal Surgery, Bariatrics and next week I'll follow the renal dietitian. After that I'll spend a week with an ICU dietitian before 2-weeks of practicum (working floors independently as an RD would).

So, what does a clinical dietitian do?? It is helpful to think of almost every health care provider (pharmacists, dietitians, physical therapy, speech, occupational therapy, etc..) in a hospital as acting as consultant to the MD. With nurses both playing the role of consultant and actually getting everything done.

Dietitians keep track of the nutritional component of patient care. When patients are able to safely eat, we stop by their rooms and encourage them, make sure they are getting their meals and "between meal nourishment's" (AKA snacks) and try to subtly slip in some healthy eating cues without being labeled as the "diet police". When dramatic changes are needed in a patient's diets (ex. new diagnosis of diabetes or kidney failure) we are sent with a packet of instructions and go line-by-line through a complete dietary change. When patients are unable to eat we act as a consultants, providing MD's with suggestions for alternative support. This may mean a enteral/tube feeding or parenteral nutrition/directly into the blood stream.

Every dietitian has the same mantra when working with alternative nutrition support: "If the gut works use it". Enteral nutrtion, the digestion of food through all or some part of the digestive tract is always the preferred mechanism of nourishment. If a patient is unable to chew or swallow a tube can be used. A nasogastric or nasoenteric a tube is placed through the nose and down the throat to the gut. While a PEG or J-tube is "surgically" placed directly through the abdominal wall to the stomach or intestine. Formula is than dripped or gently pumped into the body, and the gut completes the digestion and absorption of nutrients into the body. Enteral nutrition is used a wide variety of clinical conditions: It is used when a patient simply doesn't have the energy or ability to eat enough, when they are unable to swallow correctly (after a stroke for example), or when the stomach is unhappy but the gut is working properly. Enteral nutrition is almost always the preferred route for a myriad of reasons: It is more biologic, less invasive, less expensive and just less complicated than its cousin parenteral nutrition.

Parenteral nutrition takes alternative nutrition support to a whole new level. The smallest elements of food: sugar/dextrose, protein/amino acids and fats/lipids are directly infused into the blood stream no digestion required. Generally a central line directly into a major artery is used and the nutrition is continuously pumped in. Parenteral nutrition is only appropriate in a select number of patients, those whose digestive tract are unable or unwilling to digest food. This may happen when there is hole somewhere in the gut, after a surgery when the gut doesn't wake-up, with severe inflammation of the digestive tract or just complete upset of the entire system/major trauma. Parenteral nutrition may seem more straightforward than enteral but it is anything but. Our bodies are incredibly efficient at digesting and using food, so parenteral nutrition skips millions of years of evolution. It is anything but biologic, very invasive, incredibly expensive (more than $1,000 per day) and prone to complications. That said in select patients it is a lifesaving therapy.

MD's are only required to take one nutrition class during their training. Dietitians fill in the gaps. Providing consultation about the appropriateness of their selected nutrition regiments and offering alternatives. For our suggestions to be relevant they must be holistic, taking into consideration the other related aspects, of patient care. Since the human body is the ultimate integrated system as a clinical dietitians we review and consider A LOT of things:

• Why is the patient here now? What is their progress?
• What is their past medical history and how does it relate to their current condition?
• Daily labs
• Medications
• Output of fluid from the body (urine, waste, drains, etc..)
• Medical therapies being used (ventilator status, hemodialysis etc..)
• What are our goals? (E.g. increase PO intake, minimize loss of lean body mass, etc..)

Unfortunately, a medical record is not a clearly delineated dossier of patient history and treatment, and everything they say about doctor's handwriting is true. So, often it feels like you are detective trying to figure out what the heck is going on with this patient AND what the heck you going to suggest for them. This process repeats itself as you work through your patient list. It can be both ridiculously frustrating and incredibly rewarding contributing to the care of very sick, very sick individuals.

Clinical nutrition is simultaneously everything I expected and an entirely different ballgame.

Ps. The opening image is of the Texas Medical Center, where I am completing my clinical rotation. Check out this link for more information about the medical center and the organization's within it.