Dietetic Internship Weeks 35-39: Population and Public Health

I spent 4 weeks at the Burnaby Public Health Unit with my internship partner (we’re practically conjoined twins by this point). The focus of public health dietitians in Fraser Health is child health, specifically, children under the age of 5. Why young children, you ask? The reason is that a healthy start in life can play a large role in preventing health problems during adulthood. In short, investing in children’s health has significant long-term impact.

The rotation felt like a crash course in infant feeding and infant nutrition. It’s been a while since I had read up on those topics, so it was good that our preceptor gave us plenty of time to familiarize ourselves with the most current guidelines and recommendations.

The expert in child feeding is Ellyn Satter, an American dietitian and social worker. Not only did she write several books on the topic, her institute also conducts research on child feeding practices and problematic eating behaviours in children. Much of the guidance around infant and child feeding used by Fraser Health (and many other health organizations), come from her.

Part of the public health dietitian’s role is to be an educator and resource person for public health nurses. Unfortunately, public health RDs no longer provide direct patient care, so they work closely with nursing colleagues to make sure that parents and caregivers are receiving the nutrition messages they need.

One initiative that the public health RDs are involved with is called “Avenues of Change”. The project aims to bring the LIVE 5-2-1-0 message to families in the Guildford area of Surrey. LIVE 5-2-1-0 is a slogan aimed at older children (I think 5 and up? My memory is fuzzy on the details). It stands for: eating 5 servings of vegetables and fruits, limiting screen time to 2 hours or less, enjoying 1 hour of physical activity, and drinking 0 sugary drinks. A lot of resources went into supporting this project, including a few new handouts about infant and children nutrition. My preceptor and another dietitian developed a workshop which gave nurses an opportunity to practice using the new handouts to counsel hypothetical clients. After observing their presentation, my intern partner and myself changed the workshop slightly, and did our own presentation with another group of public health nurses. The nurses really seemed to enjoy it! They asked relevant and thought-provoking questions based on their experiences with parents, and gave great answers to hypothetical scenarios from the workshop.

During this placement, not only did I learn about infant and child nutrition, I also witnessed the importance of building great relationships with one’s colleagues. This is especially important for public health dietitians, who work with many different groups of people (nurses, project managers, other RDs) throughout the day.

Dietetic Internship Weeks 33-35, 40: Management (Part II)

I completed my second management placement at Burnaby Hospital, and I was paired with another intern for the majority of it. I contributed to a few quality improvement projects for food services, and got a taste of the clinical dietetic practice leader’s role as well.

Most of our time was spent working on projects related to food service management. We conducted a few safety audits, identified areas where standards were not met, and took corrective action to address these issues. We remedied areas of concern by providing with more  information to fill a knowledge gap, or motivating workers to adopt a new behaviour. We also looked into service improvement projects, which included trying to figure out whether the kitchen staff had enough time to make a thickened meal supplement for patients with dysphagia (yes, and it’s now a part of the menu at Burnaby Hospital), and whether we could make fresh toast using the ward pantry (no, we couldn’t find any ways of doing this without increasing labour costs). We tested and developed a few recipes for the “menu makeover” project, which was fairly similar to what I did during my last management rotation. Lastly, I drafted an emergency plan for Burnaby Hospital’s food service department in the case of water interruption/ contamination (hint, it involves bagged sandwiches).

On the clinical side, we observed meetings and helped out with projects that were part of the dietitian practice leader’s portfolio. One project was related to clinical dietitians’ workload measurements, and another was an audit on the RDs’ chart notes.

Like with any other rotation, I think management is really what you make of it. If there are projects that interest you, ask your preceptor if you can contribute it. Create your own experiences, and like someone wise often said, “never leave learning opportunities on the table.”

Dietetic Internship Weeks 31- 32: Relief (Medicine)

I flowed from the ICU to the medical wards at Burnaby Hospital for my last relief placement. Although the patients’ reasons for admission were similar to those in the medical units at Royal Columbian Hospital, I felt a different vibe– perhaps that’s just the difference between a community hospital and a tertiary site. I had lots of opportunities to assess patients, as well as design and implement nutrition care plans during this rotation. A few of my valuable lessons learned:

• Prioritize patients who area admitted with hyperkalemia, this is an acute nutrition-related issue that needs to be addressed quickly.
• A low K level doesn’t necessarily indicate refeeding syndrome, consider other sources of K losses, for instance, vomiting or diarrhea.
• Patients with face mask for O2 delivery are at high risk for aspiration. When they eat, they need to take off their face mask, take a bite, put face mask back on, chew, and swallow. All this is happening while the mask is forcing oxygen into their nose and mouth. Check with nursing for signs of aspiration, refer patient to SLP for a swallow assessment. Consider also that patients may not be on a face mask for very long.
• Talking with doctors: ask follow up questions as necessary to clarify nutrition care plan, especially when it relates to fluid status in a patient who is receiving tube feeds.
• Talking with family members or patients: use language that sets out dietary guidelines and my recommendations clearly, and be confident in the knowledge of myself and other healthcare professionals.

So with this, I ended the clinical placements of my dietetic internship. I’m so happy and proud that I passed this rotation. Above all, I’m hopeful that my patient care practices will improve based on my experiences during internship. It’s been a long journey with lots of unexpected twists and turns, and it’s not quite over yet. But I feel like I’ve cleared a major landmark, and that’s worth celebrating.

Dietetic Internship Week 30: Nutrition Care III (ICU)

This past week, I really made an effort to assess patients’ status, speak up during rounds and communicate more with the team, and ask questions when I was unsure. I’m happy to say that I passed this rotation.

I was able to identify when patients were unable to maintain their blood pressure, and reacted to the situation appropriately by slowing tube feed rates or maintaining a slow rate rather than increasing to the goal rate. Similarly, when their blood pressure control was improving, I identified these situations and suggested to increase their tube feeds to goal rate.

I also made a conscious effort to speak up more during rounds. I wrote down notes to remind myself about electrolyte replacements or other topics I wanted to discuss with the team, and spoke to the doctor when it was appropriate to do so. ICU rounds are great because  almost everyone involved in the care of the patient is there, so it’s easy to communicate and discuss among the team. Not all of my suggestions were implemented, for example, I was wondering whether we wanted to provide vitamin D & calcium supplements to a patient receiving a 5-day course of steroid therapy. The response was “no”, because the medication was short-term. A part of me knew that might be the case, but I’m glad that I asked.

Finally, I consciously tried to ask questions when I was unsure. I found this to be helpful especially when there were “gray areas” where I was unsure of how to weigh the pros vs. cons of two decisions. Talking over these scenarios with someone more experienced was helpful in learning what information is important to prioritize when coming up with patient care plans.

Moving forward, I’ll be starting relief at Burnaby. I know that the exposure to patients that I had during the ICU gave me more experiences I can draw upon to make better decisions for patients. I will continue to communicate the patient’s nutritional needs to other healthcare staff, and consult with my preceptor when I’m faced with a situation with which I don’t feel comfortable.

I can’t believe internship is almost over. I’ll be working on my cover letter and resume and starting to apply for work opportunities. Life feels a bit uncertain right now, and I’m doing my best to navigate the darkness that is the future.

Dietetic Internship Weeks 26-27: Nutrition Care III (Renal)

I spent the last two weeks between the Kidney Care Centre (KCC) in New Westminster and the peritoneal dialysis (PD) unit at Royal Columbian Hospital to learn about the nutritional management of renal disease. Much like my placement during the diabetes education centre, the renal rotation focused on preventing the progression of a chronic disease and/or symptom management through dietary approaches.

The biggest challenge to dietary counselling for chronic disease (in my opinion) is inspiring a desire to change in patients. Just because food, nutrition, and health are important to me, doesn’t mean that every patient is going to share the same beliefs. Sometimes, diet is the last thing they want to talk about. How do we do what’s best for the patient when faced with this reality? One of my preceptors really emphasized to always start the conversation by asking the patient if there’s anything I can do for them, if they have any questions I can help answer. I think that’s a great way to start the conversation, establish rapport, and understand patient’s priorities. Sometimes, she said that she doesn’t end up talking about diet at all with a patient, and that’s okay. Another point I learned is to ask patient them if there’s anything they would be willing to do to meet a certain goal. This is part of assessing readiness for change and can help to make sure the goals are realistic for patients.

One thing that I’ve been trying to work on is talking about making dietary changes with compassion and understanding. Patients are going through so much — chronic renal disease robs people of energy, and most of the patients are also experiencing other co-morbidities: diabetes, heart failure, hypertension, depression… the last thing they (or anyone) need is criticism about what they’ve been eating. Making suggestions in a gentle way, using positive rather than negative language, and explaining how the suggested change can impact what they care about are some strategies I picked up.

I learned about more medical stuff as well, like drugs commonly prescribed for dialysis/ renal failure patients, how peritoneal dialysis works, and fluid assessment in patients. Overall, I enjoyed learning about the complexities of renal disease, and it’s been a great couple of weeks.

Dietetic Internship Week 25: Research

Our research project is about current 4th year dietetic students’ perceptions of their upcoming integrated internships. When I first heard about the topic, I thought to myself: “What is the point of conducting this research? I can tell you how they feel.” And now that we’ve completed the data collection and some of the data analysis, the conclusions are similar to what I thought we might find. However, I realized the value of research isn’t solely in the results– it’s the process that we went through to obtain high quality data, and it’s the analysis of data to distill it to its most basic underlying constructs– this made our research project worthwhile.

I remember going to an art gallery and reading a display about the process that Henri Matisse went through to create large reclining nude. Seeing his creative process was eye-opening, and made me appreciate the painting so much more. He worked on the piece for over 5 months, it was as if he created 10 or 12 masterpieces on the way to the one which best represented his vision. At first, it was a realistic portrait of a nude woman. Then the background simplified, certain body parts became more exaggerated while others disappeared. Finally, the painting took on the identity it has to this day.

I feel like research is much the same way– many edits are necessary before the product is able to best conveys the essence of the data. We’re in the midst of this discussing, writing, editing, and rewriting process. It’s a time consuming one for sure, but working with this amazing group of preceptors and fellow interns makes it enjoyable and even fun.

Many thanks to those students who shared their experiences for this project, this could not have been possible without you!

Dietetic Internship Week 24: Nutrition Care IV (Relief)

A few months ago, I recognized that I was hesitant to recommend vitamin D & calcium supplementation for patients who were on long-term steroid therapy, even though I knew about the drug-nutrient interaction in theory.

What helped me get over the fear of recommending vitamin D & calcium for patients was: a) researching more into the evidence for increased calcium losses and poor absorption as a result of steroid therapy, b) knowing that no other profession in the hospital (generally speaking) spends as much time caring about micro-nutrients as dietitians, and we are in the best position to ensure adequate dosing and appropriate duration of supplementation, c) my preceptor reminding me lots of times that making sure patients receive appropriate supplementation is a big deal, and that it is within the scope of practice for dietitians to make micro-nutrient recommendations.

So you’d think from this experience I would feel more confident recommending micro-nutrient supplementation. Actually, I still felt hesitant during my last week of relief to recommend thiamine for a patient with a history of alcohol use. I reflected on why I felt that way, and I think it’s mostly because I need to know WHY I’m recommending supplements. So I looked it up. I was reminded that a lack of thiamine (more likely in heavy alcohol users) is the cause of Wernicke’s encephalopathy and Korsakoff syndrome. I read about how Wernicke’s encephalopathy is under-diagnosed, and that oral thiamine are less effective than multiple-doses of IV thiamine for treatment of Wernicke’s encephalopathy. Then I finally accepted that if Wernicke’s encephalopathy is suspected, thiamine should be recommended — risks of death from Wernicke’s encephalopathy and risks of permanent brain damage exist, while risks associated with treatment are low.

So I’ve learned to always ask about the “why” when learning about a novel practice — otherwise I’m not comfortable adopting it as my own.

I passed my relief placement, much gratefulness to my preceptor for helping me throughout the last 6 weeks!

Next: onto research week!

Dietetic Internship Week 23: Nutrition Care IV (Relief)

I’ve made it through my first week and a bit of relief, wohoo! Can I say I’m genuinely relieved?

Today, I was able to follow up with a good number of patients, and my preceptor agreed with most of my nutrition care plans. But the patients I had weren’t complex, so while a good confidence booster, I’m not sure if it’s a true indication of my progress.

My self-evaluation seem to fluctuate up and down quite frequently. At the end of last week, I felt quite inadequate. I didn’t meet my own expectations in terms of patient load, and I still felt uncertain about some of my nutrition care plans. Over the weekend, I thought about the areas which I needed to work on the most, and came up with a few actions that I want to practice this week. I emailed this to my preceptor and asked for 5-10 minutes to discuss my progress on Monday. My preceptor agreed with the areas I wanted to work on, and assured me that I was actually doing fine. That was a huge relief to hear and I’m really grateful for the feedback.

This rotation has taught me a lot about managing tube feeds, here are some of my experiences.

Transition from Tube Feed to Oral Diet:

• Do a calorie count to get a more accurate idea of what and how much patients are eating.
• When patients aren’t eating enough, figure out why this is happening, and whether you can do something about it.
  • Liberalize diet
    • If patient is on a dysphagia diet and followed by SLP/ OT, ask when they anticipate a patient will be upgraded.
    • Remove dietary restrictions if possible: sodium, potassium, fat, sugar, etc.
  • Manage GI / medical symptoms: nausea, constipation, pain, drowsiness, depression.
  • Customize diet.
  • Some patients will not eat “well” orally and we have to accept that.
• Nocturnal feeds are okay to use when transitioning, but patients should be followed closely to ensure they are eating adequately orally.
• Top-up feeds are an option: if patients eat less than __% of their breakfast, lunch, or dinner, provide ___ mL of tube feed. This gives patients an opportunity to eat while ensuring they meet their estimated needs.

Insertion of Long-Term Feeding Tube

• It’s a surgical procedure with associated risks, and the risk/ benefits should be carefully weighed before recommending to insert a long-term feeding tube.
• Discuss with SLP/ OT how long the patient is anticipated to be NPO.
• If patient is pending swallowing assessment in the next few days, then should wait until the swallow assessment is complete before recommending long-term feeding tube insertion. A few extra days with a nasogastric entube is probably worth avoiding a GJ or PEG insertion if the patient is able to start on a diet after the swallow assessment.

Dietetic Internship Weeks 19 + 20: Nutrition Care II (Medicine)

These past two weeks in the medicine ward, I came into contact with a wide variety of patients, and managed to put into practice a few of the principles I’ve learned about in theory.

I find the medical patient population tend to be older. Consequently, there were a lot of patients with dementia as a co-morbidity. Dysphagia is more common — partially due to age (I suspect) and partially due to the nature of the illness (stroke patients, for example). Tube feeds are used to feed patients who are severely dysphagic, and I’m hoping to get my first home tube patient soon. Many patients are frail and elderly, and inadequate oral intakes / malnutrition are prevalent issues regardless of the illness(es) which brought the patient to hospital. With multiple co-morbidities and often a long past medical history, there are more factors to consider when deciding an appropriate nutritional intervention for patients.

Fluid Balance

• Especially important for patients who have renal failure (chronic or acute), are on dialysis, have liver damage (ascites), and chronic heart failure. Want to ensure adequate hydration but not fluid overload.
• Assess the amount of fluids in vs. out: check nursing notes to find out the amount of fluid the patient is receiving via IV and medications, if possible.
• Assess edema — check feet, legs, hands, and arms.
• Assess ascites.

Alcohol / Drug and Micronutrient Interactions

• Recommend vitamin D (1000 IU OD) and calcium carbonate (1250 mg BID) for patients receiving long-term epilepsy (dilantin) or corticosteriod (prednisone) treatments.
• Folic acid may interfere with the effectiveness of dilantin in a small percentage of patients. Patients on dilantin are more susceptible to becoming deficient in folic acid. Recommend supplementing folic acid and monitoring dilantin levels in consultation with pharmacy.
• Alcohol abuse: supplementing folic acid, thiamine, B6 and B12 are not unreasonable, especially if a patient has cirrhosis. Probably easier to take a B-complex vitamin.
• Bile acid sequestrants (for example: Questran), may lead to fat-soluble vitamin deficiency in the long-term. Consider supplementing with a multivitamin daily.

I think I’m improving with regards to designing appropriate nutrition care plans– however, one area I would like to improve is anticipating and planning for upcoming changes, such as patient discharges. This is important especially for patients who need diet-related information prior to discharge. To learn about patient discharges, I could attend rounds more regularly, speak with the patient care coordinator, and of course, just ask the patient. If a patient is needing diet education prior to discharge, I need to find out to where they’re getting discharged (back home, to a residential facility, or to a different hospital/ ward), and provide information accordingly. Another unexpected thing to plan for– patients who are scheduled a swallow assessment may not get them on that day (barriers to assessing swallow: level of consciousness, inability to manage secretions), should come up with a plan in case this happens (?EN, or dextrose containing IV), especially if patient has been receiving inadequate nutrition for a few days. Talk about this plan with other members of the healthcare team (nurse, doctor, SLP/OT, etc).

So I have one more week in nutrition care II before starting relief, it’ll be a short one with Monday being Family Day and a pediatric symposium in the afternoon of the Thursday, but I’m really happy about the progress I’ve made in the past weeks ad am looking forward to the new patients I’ll get to see next week!

Dietetic Internship Week 16: Nutrition Care II (Surgery)

Happy 2015!

This was my first week back from Christmas break and it was a bit of an adjustment returning to an inpatient setting once again. I’m on the surgery ward at RCH, and most of my time is spent with general surgery patients who’ve received some sort of GI surgery. There’s been a lot of new medical / surgical procedures that I needed to learn, and I’ve been trying to read up on them during my spare time.

Being in nutrition care II, the expectations of this rotation include coming up with nutrition care plans independently. This is something that’s been challenging for me throughout my NCI placements. I think part of the reason I struggle with finding an appropriate intervention is I’m not able to assess the patient’s status appropriately– I’m missing information or not realizing the clinical significance of a piece of information at hand. Sometimes it’s also hard for me to recall what exactly a patient’s nutrient requirements are for a given disease condition, so I don’t have a clear goal to work towards (knowledge gap). Part of the reason is that I’m not aware of the possible interventions available– I need to build up my reservoir of available tools and choose the most appropriate one for the given situation.

One aspect of my performance I really want to improve this week is coming up with a good intervention and backing it up with a logical rationale. To do this, I need to ask lots of questions– why questions: why am I choosing this intervention? why do I think a patient needs _____? why is this the most important nutrition problem faced by this person? When I can answer those questions… then I’m ready.