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.
