After I spent the week in pediatrics, as I mentioned in my last recap – I spent the next 2 weeks in Patient Services.

Patient Services is a management/foodservice type of rotation and is a very unique position for a RD to be in. Patient services mainly deals with the foodservice side of a patient’s stay in the hospital. Patient services deals with patient problems with their food – whether it be missing items, complaints, preference issues, etc. We had daily meetings where we met with the patient services management team, our trayline management team and our patient ambassador team. In these meetings, any issues that arise with the roughly 1200 beds we serve daily were addressed and dealt with.

The RD is responsible for dealing with dietary issues – whether it be a diet order problem, a question of availability with a diet, or a food preference issue that is dealt with by our diet techs. The trayline management team handles any problems with incorrect orders or foodservice problems that can be managed when the food is actually placed on the tray. The patient ambassadors round on about 60 patients each per day, handling patient complaints and working constantly to keep our patients happy with the food provided.

Organizationally there is generally an ADPS – or Assistant Director of Patient Services in a hospital, which is a position required to be filled by a RD. At our hospital, our most recent ADPS left and was replaced with a general patient services director, who is not a RD. However, we have a patient services manager who IS a RD – and is who I spent the majority of these two weeks working with. The fact that we have a larger organizational structure allows our hospital to work around this requirement.

Why is this necessary to be a RD position? Like I mentioned, patient services is really the branch between the clinical work done on a patient’s diet and the delivery of the food from the kitchen. Some patients in our hospital are on selective menus – where they can order what they want from a menu, while others are on a stock hospital menu. These food preferences have to align with their diet order, which takes a RD with clinical experience to help manage this process and ensure the kitchen is providing the correct items.

Truthfully, this is a rotation that would have been more beneficial for me in the beginning of the year because I learned so much about how a patient’s diet and menu choices are managed in the kitchen. I learned about how I could help patients solve their food problems, or help them to find items on the menu that would benefit their nutrition status or help them when they were having menu fatigue. I finally understood the entire process of what we can manipulate as clinical RDs to help our patients.

Regardless of the timing, I learned a great deal in this rotation. We worked in the trayline manager position for two different meal shifts – checking trays for accuracy and dealing with patient issues. We completed test trays and worked to improve tray accuracy and temperature requirements. We rounded on patients to learn how we can improve our foodservice operation and then communicated these findings to management in team meetings.

We also did a fair amount of general management. Our patient services manager is responsible for our diet techs, record clerks, diet clerks and patient ambassadors. We participated in performing audits for her team and employee roundings. We worked on management projects to improve work productivity. We wrote a letter to Centers for Medicare and Medicaid services petitioning them to pass a national law allowing dietitians to order diets and supplements for patients on their own, without requiring doctor approval (which is something we have at Baylor, but many hospitals do not). We worked on floor stock for our units and re-organized nutrition rooms on the units. We even delivered food trays one day to patients!

Over the two week period, we were VERY busy with all the assorted tasks I mentioned above. Basically – if it had to do with the patients meals or managing the staff that takes care of patient meals, we worked there!

In general – this is a very different foodservice area compared to all our other rotations. Mainly the difference lies in a RD being required in this role. However, it was a very interesting 2 weeks and I learned SO much about foodservice and how it works with my work on the floor as a clinical RD.

Any questions about Patient Services?

During my internship, we have a total of 5 weeks of clinical pediatrics and 2 weeks of community pediatrics. I’ve already blogged about 3 of these 7 weeks here:

NICU (2 weeks)

Pediatric Outpatient GI Clinic (1 week)

Head Start (1 week)

I have another pediatric rotation recap for you, but I’m naming this one specialty pediatrics 1, because the other two clinical weeks I went through were a mix of different specialty conditions children face. I figured this is a good way to describe what I went through without focusing too much on the facility where I was.

So, the first of these specialty weeks was done at Baylor’s only children’s hospital – Our Children’s House. Here I saw children who had the following conditions:

1. Feeding Disorders/Inpatient Feeding Therapy Program

2. Ventilator children/Vent Clinic

3. Rehab kids (which was very similar to my rehab rotation).

It’s kind of a weird mix of patients, but I learned by the end of the week how to treat all of these kiddos nutritionally. Let’s break down each diagnosis and talk about nutritional concerns.

Feeding Disorders

Feeding disorders are fascinating. Seriously, this was one of the coolest patient populations I have worked with throughout my internship. There are a lot of reasons that children develop feeding disorders. They can manifest as oral aversions – generally because the child was tube fed for a long period of their life. They can appear due to dysphagia, or difficulties swallowing from various diagnoses. They can be a side effect of an overlying disorder – such as autism or a food allergy. Or, the child can just have one!

For whatever reason, these children are very difficult to feed. They often will only eat certain foods, certain textures, foods in certain patterns or in certain environments. They often refuse food and their nutrition status and growth can be impacted by their refusal. This hospital offers an inpatient feeding program to parents where the child stays at the hospital for several weeks and participates in feeding therapy every day with a multidisciplinary team.

I’m going to try to describe feeding therapy, but considering I’ve only seen a few sessions – know that I am NOT an expert in this area. Feeding therapy sessions are one of the coolest things I’ve ever witnessed. In feeding therapy, children are placed in a controlled environment, where they have set meal times and go through training to eat bites of foods and takes sips of liquids, in order, after given cues– then the child is provided positive or negative responses depending on their behavior.

The child starts in the room during their sessions with just a feeding therapist, with the parents and the feeding team watching behind a double mirror. The child generally has 20-30 minutes for this meal and if they choose to take zero bites, or choose to take all bites – it’s the exact environment and cues every single time. Unlike with normal children, these children are generally offered toys or a video to give them a positive incentive to take bites and follow their prompts and directions. If the children throw a tantrum – the feeding therapist remains exactly the same, giving the same prompts and taking away their toy or video until the child follows the prompts.

The children generally go through these therapy sessions 4 times a day, and are offered different foods and textures slowly as the sessions progress. These sessions are extremely regimented and everything is weighed before and after the session, so we know exactly down to the gram how much that child ate during the session.

Slowly but surely, the parents become involved. At first after observing outside the room, they sit in the room in the back of the corner. You can imagine that a lot of times once the parent makes it into the room, the child starts to act differently and sometimes regress. This is another process – for the child to learn that no matter what they try, they have the same expectations and their parent will not give into their tantrums or actions.

Then, they will progress to the parent offering the food and providing the cues the child has been trained to learn. Once the parent and child can overcome their previous issues and the child is eating more and accepting more foods/textures, they will eventually go home and trial this process all over again back in the child’s home environment.

It’s a lot of work for everyone involved, but it’s very successful – so long as the parents can maintain the structure that the child learned during the therapy program.

Ventilator Children

This hospital offers an inpatient program for children for ventilator management/teaching for families – and also for ventilator weaning. They also have an outpatient ventilator clinic, where long-term ventilated children will come for their care visits.

When anyone is on a ventilator, their calorie needs dramatically drop because their body is no longer breathing completely on their own. Also, fluid status is very important in these patients – because “a dry lung is a happy lung.” When patients on a ventilator have too much fluid, it can lead to excess secretions or excess fluid coming into the lung, which can lead to problems with aspiration, breathing or place strain on the lung.

The dietitians are very involved in the nutritional care plan for these patients – dealing often with tube feeds and water flushes, and ensuring the patient is not being over fed or taking in too much fluid.

Rehab

I’m not going to spend any time here, because I’ve already discussed rehab care in that rotation’s recap. But these kids were typically fine before their accident and are now receiving therapy and rehab care in this facility.

Overall – this was a very interesting and diverse rotation. I loved the feeding program and the rehab kids. I didn’t love ventilator kids, just because I’m really not a fan of tracheostomies, and this facility requires that all ventilated patients come into the facility with a trach.

Can I answer any questions about the types of patients I saw in this rotation?

Another internship recap. I’m only a month behind

After my renal/pharmacy/shadow week – I spent a week in Bariatric Surgery counseling. I know people probably have a lot of questions about this, so I’m going to try to cover everything in this (longer) post.

Unfortunately I didn’t have the FULL bariatric counseling experience. The RD in our system who was the preceptor for this rotation (and did bariatric counseling full time) left in the fall of last year, so the interns who had not been through this rotation were split between two other clinics. One of those clinics is also full-time bariatric, the other is just an outpatient clinic that sees a lot of bariatric patients.

I ended up in the outpatient clinic, so this was basically a repeat of my outpatient rotation – with more bariatric patients than I had in my outpatient rotation. This being said, I was not upset with the week. I learned a lot and I love outpatient counseling, so I really enjoyed the week.

I wish that I could give you black and white rules/regulations for bariatric surgery – but it’s VERY dependent on an individual’s insurance policy. Every insurance policy requires different things for people to qualify, and then each surgeon has their own routine and regimen that they follow.

However, I will tell you that GENERALLY the requirements to be eligible for bariatric surgery include:

1. A BMI of >40 kg/m²

OR

2. A BMI of >35 kg/m² with two co-morbidities (such as diabetes, sleep apnea, hypertension, etc).

If you don’t know how to calculate your BMI you can pull up a calculator here.

Also, most insurance companies require the following:

1. 1-3 sessions pre-operatively with a dietitian.

2. Assessment by a psychologist

3. Sleep Study

4. Stress Test

5. Physical/lab work with the doctor

Whatever the specifics are for that insurance policy, all involved healthcare professionals have to sign off on recommending a patient. This means that when a dietitian is involved, the dietitian is able to say whether they would approve the candidate for surgery or not.

These regulations are obviously subject to change at any time, so do not quote what I say. Just know that’s what I was taught in this rotation.

Let’s get into more specifics about the process. There are three types of bariatric surgery that most people get:

(source)

The Gastric Band is the least invasive, but the least successful. Patients typically lose 50–60% of their excess body weight. It’s very easy to stretch the pouch with this operation because it’s not a permanent option and the band deflates over time.

Gastric sleeve is the “most popular” I would say and is 99% of the patients who I saw during my rotation. This is where part of the stomach is literally cut out of the body and made into a “sleeve”. Patients are expected to lose 60-70% of their excess body weight.

Roux-en-Y is the oldest of these three, and the “most successful” with patients losing 70-80% of their excess body weight.

The 4th one in this image, the biliopancreatic diversion with duodenal switch is the “newest” form of bariatric surgery, and is basically MORE malabsorptive than the Roux-En-Y. It’s just starting to emerge.

The diet for the sleeve and roux-en-Y are very similar and are what I taught patients in this rotation. Because every surgeon has a different diet plan for patients to follow, I will tell you some general highlights from the surgeons I worked with in this rotation.

1. Patients are on a liquid diet for 1-3 weeks prior to surgery. This is to reduce the size of the liver so it does not complicate the operation.

2. Post-op, patients are on a liquid diet for 3 weeks and then can only eat soft/easy to pass foods for 3 weeks following that period. They have to wait for their stiches to heal, 6 weeks post-op, before they can eat anything that can’t pass through a strainer.

In this first 3 week liquid diet phase, the patients can only tolerate about 1oz of fluid every 15 minutes. The #1 reason people re-admit to the hospital post-operatively is due to dehydration, so this is a huge problem. We teach patients to have a “shot” of liquid every 15 minutes from the time they wake up to the time they go to bed during this time.

3. Adequate protein intake is critical post-op and all patients will be on a protein drink/supplement during this 6 week period. This is because of the increased needs from surgery and because of the level of malabsorption.

4. Once patients are able to eat solid food – they have to eat protein first, then vegetables, then their starch. They will take 2-3 bites protein, 2-3 bites vegetables, then 1 bite starch and repeat until they are full. This protein makes a “plug” in the pouch so that the starch doesn’t slip through and readily digest, which can cause dumping syndrome.

5. Vitamins are also necessary due to the level of malabsorption. All patients must take a multi-vitamin twice daily, calcium three times a day and a b12 vitamin once a week. These ALL must be chewable, for life. Based on their lab values and/or history of anemia, patients may also need an iron supplement.

6. No carbonated drinks for life. No straws either.

7. Some surgeons say no alcohol ever again. Other surgeons say no alcohol for 1 year. It just depends.

8. Patients will always have to separate their fluids from meal time. No drinking 30 minutes prior, during or 30 minutes after eating. Fluid fills the pouch so they are unable to fit as many nutrients through food into the pouch if they are drinking during eating.

9. Consistent exercise is required for patients to lose and maintain their weight loss.

If patients stop following their meal plans and begin to “stretch” their pouch (thus leading to weight gain) it will never shrink back. This means their surgery was essentially pointless (from a weight loss aspect) if they stretch their pouch back to the point where they are able to eat the same portions they were eating prior to surgery.

There is research showing that through an unknown mechanism, bariatric surgery can “cure” diabetes prior to the patient even losing weight. If the patient re-stretches their pouch, it’s not guaranteed their diabetes will come back – but it is highly possible (as fat cells are the most insulin resistant in the body).

****

I have to say that when I entered my internship I was absolutely against bariatric surgery. And now that I’ve worked with it so much and the patients, I am still very conflicted with the process. We happen to have great surgeons who are very diligent with patients, but I’ve heard many stories from patients who didn’t have surgeons who followed them post-operatively, or didn’t provide all the information they needed to know up front – and thus had unsuccessful operations or complications after the surgery.

It’s also hard for me to agree with some people receiving bariatric surgery. The thing that I never really understood until I finished this rotation is that receiving bariatric surgery and following all the directions for successful weight loss post-operatively is a lifestyle change. The patients who are most successful eat balanced meals, they exercise regularly, they continue to eat smaller portions and follow their post-op diet restrictions. For people who are not at an immediately health-risk pre-operatively, it’s hard for me to recommend surgery when I know they could lose weight making the same changes just without having the absolute restriction of a surgically altered body. But, that’s not my decision to make for them and that’s probably the hardest thing I’ve learned about any of my patients in this internship.

Anyway, in the end – if I want to be in outpatient counseling, I’m probably going to end up counseling these patients and it’s not my call what they decide to do with their own body. So I will help whoever needs my help to be healthy in the way they deem acceptable for their life.

I just know that when I look at people who are that 35-36 BMI range, I think back to when my BMI was 35. I thought a lot throughout this rotation about what it was like when my BMI was 35, how I could relate to so many of the patients we saw, how I remember not being able to cross my legs when I was sitting in a chair, how I had no energy, how I backed out of social functions due to my weight. I was really sad for a lot of the patients and ultimately, I want them to be healthier and have a happier life. At the end of the day it’s sometimes hard for me to justify bariatric surgery, but I will say I’ve learned to put it aside professionally to just help patients without having any judgment towards their decisions.

What questions can I answer about bariatric surgery counseling?

Hi all, another internship post for y’all!

The week after school foodservice, I very quickly rotated through three different areas:

1. Renal/Dialysis

2. Pharmacy Sales

3. Shadow day of my choice – where I spent another day in Organ Transplant, but at the Fort Worth Baylor hospital!

Renal

I spent three days of this week in Renal at two different dialysis clinics. In dietetics, renal dietitians are not an entry-level position. You have to have at least 1 year of clinical experience before you can be a renal dietitian in most places. Therefore, this rotation was mostly observational – and just an introduction to show what a renal dietitian does.

For those that aren’t familiar – renal is a fancy world for the kidneys. Dialysis is a process for people who are in kidney failure, where a machine and solution act as an “artificial kidney” and filter the body of waste that is normally filtered by the kidney. People have kidney failure for many reasons, though most commonly (and avoidable) due to uncontrolled diabetes or high blood pressure. But some people have congenital kidney problems they are born with, or maybe only have one kidney and have some sort of trauma or other problem that causes them to enter kidney failure.

I’m not going to talk about all the specifics about renal disease (because it can be pretty advanced and confusing) – but as always, if you have specific questions please let me know.

Two of the three days I spent in hemodialysis, which is the most common. Hemodialysis is filtering of the blood. These patients come into the dialysis clinic three days a week for about 4 hours each time to have their blood filtered.

(source)

The other day I spent in a peritoneal dialysis outpatient center. Peritoneal dialysis is where a liquid solution is infused into the peritoneal space in the abdomen and waste products are pulled into the peritoneal space, where later the fluid is drained along with the waste products. This is a much more flexible type of dialysis for very motivated and self-sufficient patients. Peritoneal dialysis has to be done every day, by the patient sometimes overnight or sometimes during the day.

(source)

A renal dietitian is one of the key health providers for the dialysis patient. Dialysis causes a lot of stress on the body and kidney failure prevents certain foods from being eaten because they cause a build up of the waste products that are generally excreted by the kidneys. The RDs help patients manage all their diet so their lab values remain in proper level and more permanent harm is done to the body.

For hemodialysis, the most important nutritional concerns are to eat high levels of protein (because protein is pulled out of the body by the dialysis process) and to limit their intake of phosphorus, sodium and potassium. Often these patients are on phosphate binder medications, because phosphate is an additive in almost all processed foods – and is extremely hard to avoid in the diet. However, this patient population is not always the most compliant with medical advice – so the RD has to round on them almost every time they are in the clinic to check on their labs and progress. Many do not even remember to take their phosphate binders and they aren’t limiting phosphate in their diet.  High phosphorus levels in the blood can lead to metabolic bone disease, which ultimately can cause bones to disintegrate and may cause death.

A renal RD who came to present to us in the beginning of the year told a story about a patient who never took their phosphate binders and never followed the proper diet. They definitely had metabolic bone disease and one day went into cardiac arrest. When the health professional who initiated CPR on the patient went to pump their chest, their sternum and rib bones shattered and the patient died because of the blunt trauma to the heart. So, metabolic bone disease is no joke my friends.

Anyway, being in the dialysis clinic was interesting. Admittedly, I was in a low income clinic and as I mentioned – the dialysis patient population is often not compliant with recommendations. So, it was often a little frustrating for the RD I was working with. However, she sees her patients at least 2 days a week (for life, or if they get a transplant) and rounds with the doctor, so it’s a good job if you want to continually follow the same patients. And it’s VERY hard – arguably one of the most difficult dietetic fields to work in.

I can’t say I’m dying to be a renal dietitian – but I wouldn’t cross it off my list yet. I hear it’s definitely something that people feel very strongly against doing – but later in life decide to do it and love it.

Pharmacy Sales

We spent another day this week with a pharmaceutical sales rep, who was a RD, who sells nutrition support formulas and oral supplements to hospitals. This is one of the highest paid jobs in dietetics, so it was very interesting to spend the day with her and hear all about her job. She also walked through ALL the products her company carries, which was fantastic information for me to continue to expand my knowledge around the specialty tube feed formulas.

Unfortunately we were supposed to have a client meeting with her that day, but it was cancelled. I can’t say that I saw her in action – but we also have come into contact with many sales reps who come and provide lunch and learns to us, so I am familiar with the career.

Again, can’t say I’m dying to do this job – but I also wouldn’t rule it out!

Shadow Day – Transplant in Fort Worth

I’m not going to recap this because I have an entire post dedicated to this area. But it was great to spend another day with transplant patients. It was even better to spend the day at the Baylor hospital in Fort Worth, because I am doing my Staff Relief there and am going to work PRN over the summer.

Can I answer any questions about Renal or Pharmacy Sales?

Another internship recap! I am desperately trying to get caught up on these, but we have all these little 1-off things that are due this month (as we wrap up our internship) – so I’ve been swamped with all of that!

After I finished my Oncology rotation, I spent a week in School Foodservice. This rotation was not like a traditional school foodservice experience. When I was in school, I spent actual time in school kitchens working with with the foodservice staff – preparing and serving food to students. This rotation was much more management/director focused, which is the role a Registered Dietitian would actually have in a school foodservice operation.

We spent a week with the Nutrition Consultants who work for Region 11 in Texas. They have three RDs who act as consultants to school foodservice directors and menu planners in all the school districts that are part of Region 11. These consultants mainly help the individual districts to plan their school menus to comply with the USDA School Breakfast (SBP) and School Lunch Programs (SLP). This is very important to ensure that schools are receiving reimbursement and commodities that are part of the USDA programs that allow students to have free and reduced lunches.

I’m not going to go into all the specifics about the USDA programs – but I will tell you that school lunch requirements are VERY different from when we were in school, my friends. And actually, they will be completely different in 2-3 years than what they are right now as the USDA is in the process of implementing a lot of changes to these programs.

The majority of our week was spent working on projects. The main project was to plan a 1 week menu for both breakfast and lunch, which had to adhere to the new SBP and SLP standards that will be in place in 2014-2015. This took us QUITE some time, as menu planning is a very tedious and intricate process. We also had to write 4 new recipes (scaled recipes, mind you) for red/orange and green vegetables – that we included in our menus.

We also worked on creating, writing and filming nutrition education videos that will be shown on a school district’s website regarding 1) healthy beverage choices and 2) the importance of dairy foods. I was hoping that by now these videos would be up and I could link to them, but I haven’t heard back about when they will actually be live.

To prepare for this presentation, we visited a elementary school during lunch to see what beverage choices students were making, and what beverages they were bringing from home (as most sugary drinks cannot be purchased in Texas schools). We then took the top offenders and showed in the video how much sugar is actually IN these drinks.

We had fun while filming the videos and tried to make them appeal to elementary students. Abby and I filmed with the Registered Dietitian for the school district, who has filmed other videos for her students. I played the role of a Chef and Abby played a Scientist. It was VERY nerve wracking, but we had a lot of fun doing it – so that was good!

One day during the week, we actually spent the entire day at a school district – working with the School Foodservice Director (who is a RD) and their Registered Dietitian, who is responsible for both menu planning and nutrition education (the same RD as above).

We were able to eat in the cafeteria for lunch, after talking with students about their beverage choices. This school district is already on the forefront of the new nutrition standards. They serve ALL whole grain and have been implementing new foods for the students to try, like kale chips!

While there, we had the following for lunch: whole grain Mexican lasagna (which is vegetarian, but don’t tell the students!), milk, salad, corn and strawberries. Let me just say, those strawberries were the BEST strawberries I have ever had.

Some of the teachers in this school are VERY supportive about the nutrition initiatives the RD and director are trying to implement. We witnessed Kindergarten teachers who would go get the strawberries or salads and eat them while walking around the students, playing the role model to encourage the students to go back to the line and get their own fruits and vegetables for their tray.

Overall, it was a GREAT (but busy) week. I loved seeing the direction that school breakfasts and lunches are headed – and having the first hand experience of menu planning gave me a very real appreciation for how much school lunches have changed – and the potential they have in the future. I loved the responsibilities of the consultants and how much education and teaching went into their job. While I’m not particularly interested in foodservice, I would definitely consider this role at some point in the future for my career.

Can I answer any questions about school foodservice or anything regarding the USDA standards for SBP and SLP?

DI recap!

I will admit, it takes a lot to talk me into writing these now. I’m really looking forward to getting back to regular, pretty with pictures, talking about food, blogging.

BUT! ALAS! I promised to see this out through the year, so damnit – I’m going to do it.

Also, I’m fairly convinced no one reads these anymore – so that doesn’t exactly motivate me to continue writing. But hopefully someone will find these useful one day.

Oncology was a two week rotation, where I spent one week in outpatient and one week in inpatient. This was actually my LAST adult clinical rotation – so it was quite bittersweet. It was also very similar to my Bone Marrow Transplant rotation – which means it went by smoothly.

outpatient

All the interns have raved about how much they loved outpatient oncology, so I was definitely expecting to fall in love with it. Truthfully, I didn’t feel that way – BUT I think if it was my full time job, I would love it. The problem was that as an intern – it’s really difficult to see patients who have such an established relationship with their oncology dietitian. Some of these patients have been seeing their RD for years and years – so to be the intern trying to 1) Know their history/what they’ve tried and liked, etc and 2) Gain their trust in one 15 minute counseling session is hard.

Very often, patients would answer my questions – while looking at my preceptor instead of me. It is also very uncomfortable, no matter who it is, to counsel patients with your preceptor in the room. It’s just life. But – I did what I could and helped who I could.

There were two general categories of patients that I saw. Most of these patients we saw with the doctor, so we were in the room at the same time as the doctor spoke with them. That was a little intimidating as an intern, because I am not used to working in an oncology environment – where everything is raw and not always optimistic. I think you hear someone has cancer, as just an average person, and you freak out. So to be in a room with people who do have cancer, who don’t have always have a good prognosis, and to hear a doctor speak of that very candidly is hard at first. I SO OFTEN thought, oh my gosh – this poor patient has cancer and it’s bad. I spent a lot of time putting my professional hat back on and thinking, okay – so how can I help them? Rather than just be in awe and concern over their diagnosis.

Because we visited patients whenever they came in for their doctor visits, we rarely saw patients who came in JUST for a nutrition appointment. We also saw some patients in Chemo or Radiation, if we missed them during their office visits. How these two categories of patients were handled very differently nutritionally, so let me discuss that.

1. The first group was head and neck cancer. Most of these patients have both Chemo and Radiation. Radiation to the head/neck area basically ruins their oral intake. It causes mucositis, sores, swelling, dysphagia (problems swallowing), causes problems with heartburn, saliva production (both too little and too much) and general mouth pain. These patients are at an extreme nutrition risk when radiation is involved. Plus throw on the general Chemo complications, like nausea, vomiting, diarrhea, constipation, taste changes, early satiety (the list goes on).

The doctor that we worked with in the head and neck population requires his patients to get a feeding tube. So these patients spend about a year following this sort of diet progression (which lasts well after treatments end).

Normal diet
Bland/soft diet (start introducing supplements)
Liquid diet (start adding tube feeds if needed)
Nothing by mouth/Tube feed dependent
Liquid diet (weaning off tube feeds)
Bland/soft diet (with oral supplements)
Normal diet (may still need oral supplements)

It’s brutal. So many of the patients are afraid of getting off their tube feeds, so that takes some coaxing and sometimes removing the tube even before the patient has weaned themselves off the tube feed. So – obviously the RD walks them through the phases of this process and sees them weekly, while they still have the tube, and generally every 2 weeks to 1 month after the tube is gone and treatment is done. They then move to seeing them when the doctor sees them in the clinic.

2. Pancreatic/Gastric/Colon/Rectum/Lung/Liver/Some blood cancers. These were all handled very similarly. Very few had tube feeds and most weren’t getting radiation. If they were getting radiation – it generally wasn’t affecting their GI tract the way it does with head and neck cancer.

Most of these patients just had problems related to the chemo. So a lot of nausea and vomiting educations, a lot of trouble shooting problems with diarrhea or constipation. We spent time educating about options for taste changes with patients as well. We educated of course on oral supplements and calorie boosters in foods – which are huge in this population. For the pancreatic cancer patients, we spent a lot of time recommending/educating on using pancreatic enzymes or a low-fat diet.

inpatient

Inpatient is really nothing to write home about. It’s very similar to both outpatient and all the other inpatients you see in the hospital. Really, the people who are admitted to our inpatient unit are just people who weren’t doing well in the outpatient setting. Often these patients were dehydrated, or didn’t have feeding tubes – and had almost no oral intake. I had several people on tube feeding, one or two TPNs during the week. I did a lot of work with food preferences, ordering oral supplements/milkshakes for patients, encouraging bland and cold foods for patients with bad nausea.

We also helped out on the Bone Marrow floor, so I saw one or two of my former BMT patients while I was working.

So – my last adult clinical rotation of the internship until Staff Relief! The rest are foodservice, community or pediatric rotations left!

Anyone have questions about Oncology Nutrition that I can answer for you?

DI recap! This particular rotation was split between two locations, so I’ll break them apart

Head Start

I’m not sure how many of you have heard of Head Start? I definitely had not until I started my internship. I have tried again and again to summarize what Head Start is in an eloquent way, but I keep coming to a loss. So, I will give you Wikipedia’s summary (not that I support citing from Wiki, but in this case – it’s the best summary I could find.

The Head Start Program is a program of the United States Department of Health and Human Services that provides comprehensive education, health, nutrition, and parent involvement services to low-income children and their families. The program’s services and resources are designed to foster stable family relationships, enhance children’s physical and emotional well-being, and establish an environment to develop strong cognitive skills.

Head start looks like pre-school, but it’s much more involved than that. It’s available for infants through children who are 5 years old. In Dallas, children are enrolled in Head Start while they are still in the womb. There are some Head Start locations that are located in school districts, while others are in their own buildings.

Nutrition plays a huge role at Head Start. The children are taught nutrition education lessons. They learn to eat at a table, starting at age 1, and learn to serve themselves from a family style set-up (including pouring their own milk) starting around 18 months. They are fed a balanced meal every day – which is generally made from scratch, rather than what we all assume a typical school lunch to be. The children’s height and weight are assessed quarterly and children who are at nutrition risk are identified and interventions are done.

There are a lot more details about the nutrition program at Head Start, especially in the Early Head Start – where children are transitioned from formula/breast milk to solid foods. But I’m just giving you a general summary – you can ask me specific questions if you have them.

Head Start in Dallas does not employ ANY RDs. The director of my internship program reviews and approves their menus for nutritional adequacy – and in exchange for her services, all 12 of her interns rotate through Head Start for a 4 day rotation. We have a mixture of both working with the Head Start program and a Corporate Wellness experience, working with the staff at the main administrative office.

During this week, we had several projects we completed that satisfied both of these rotation experiences. The director is extremely supportive of dietitians, so she has us help her educate her staff and parents.

• Myself and another intern made 4 newsletter articles/handouts on nutrition topics. The topics we were given included:

1. What is a RD and what do they do?
2. Insurance Companies and incentives or consequences for lifestyle choices
3. Colorectal Cancer Prevention with Nutrition
4. ADHD and Nutrition for children

• Give a presentation to the administration staff on Arthritis Prevention/Treatment with nutrition
  
• Give a 5 minute presentation to 3 year olds about the role of oxygen in the body
  
• Teach/Conduct a yoga lesson for the same 3 year old class
  
• Complete weight and height assessments for a Head Start class
  
• Eat with the students

Overall – it was such a GREAT experience! It was fascinating to see how well the children could feed themselves at such a young age and how well they were eating. The day I attended we had milk, chicken and brown rice casserole, broccoli and pineapple.

Dental

Connected to Baylor University Medical Center is the Baylor College of Dentistry. The college has a RD on staff who is also a Dental Hygienist. Her job is to educate the hygienists and dental students on Nutrition, and recognizing nutrition problems and deficiencies through dental examinations.

She actually taught us all a class back in our Introduction to Clinical week on Oral Health and Nutrition, as well as helping us learn how to perform Oral Cancer Screenings. During these classes, she challenged us to all look throughout our rotations at the nutrition problems we see patients have that are related to their oral health. I have been doing this in the back of my brain throughout the year, and it really makes a huge impact.

We only spend 1 day with her in a true Dental Rotation – but it was a really meaningful rotation for me. For those that don’t know, my brother is actually in Dental School right now – so we already spend a lot of time talking about the crossover between Dentistry and Nutrition.

We ALL avoid the mouth and problems with the mouth – both in our personal lives and in the medical professions. Obviously nutrition is VERY involved in the GI tract – and the mouth is where this starts! But most people just assume that oral/teeth/mouth problems are not nearly as serious as other body problems – when actually, the mouth is the gateway for systemic problems all over the body.

For this rotation, we have to complete a 3 day food recall – which we go through with the RD from an oral health standpoint. We discuss things that impact the mineralization of the teeth – like fermentable carbohydrates (like fruits and even whole grain products too!) and acids from drinks, even including sparkling water! Essentially anytime that you eat something that is carbohydrate – without having protein or fat as a buffer, you are placing your teeth at risk for demineralization, plaque and cavities. Same goes for drinking beverages – ANYTHING other than water.

We discussed strategies for fighting this demineralization –

• Making dietary changes like adding protein or fat to high carbohydrate meals
• Brushing and flossing teeth after meals. If these options aren’t realistic/available, rinsing the mouth out with water
• Drinking anything other than water with meals and with a straw. If you are drinking it in between meals, not sipping on it for long periods of time
• Chewing gum with xylitol right after meals (Trident is what she recommended and what we carry at the hospital for this reason).

I have horrible (genetic) gums and have to go to the dentist every 3 months. After the FIRST talk this RD gave us last August, I’ve been flossing my teeth much more regularly. At my last dentist appointment, I got bumped to appointments every 4 months instead of every 3 months because my gums looked SO good. So this just goes to show, these simple acts DO make a difference.

And after going through my diet recall, I make a point to try to remember chewing gum after breakfasts and snacks in my car (highly carbohydrate meals).

One other thing we did during this rotation was visit the The Center for Maxillofacial Prosthodontics. This clinic makes prosthetic pieces for people who are born without certain facial features (like ears, or noses) – and for patients who lose these features due to cancer. If you have some extra time, I highly recommend visiting the above website. It’s absolutely fascinating the things they do!

Any questions for me about either Head Start or Dental? I hope you all are thinking more about your Oral Health now!

Remember when I wrote my strength challenge? Let’s use that as a guide for the timeline I’m about to post.

By the way, I failed miserably at that challenge – and here is why.

The weekend BEFORE I wrote that post (which was a Tuesday, btw) – I felt awful. I was sick for 3 weeks in December, so I knew I needed to take it easy. I did nothing that entire weekend, and I definitely felt better – hence making a strength challenge that Tuesday.

Fast forward to THAT weekend, which was valentines day weekend. I felt fine until Sunday – BAM sore throat, felt like death again.

By the way, here was the outfit I wore to our super nice dinner out for Valentines day (since we don’t discuss le fashion much anymore)

Worn with a black skirt, black tights and coral wedges

Anyway – that Sunday, sick.

Actually, instead of just go through the whole timeline – just know it’s been this nasty vicious cycle. I feel sick, do NOTHING – stop exercising, don’t eat as well as I normally do —> feel better, live life again, run a 5K —-> SICK. And again, and again.

And what is today? Sunday. Know what I have? A sore freaking throat.

Being sick when you are a dietetic intern is 1,000 times worse than being sick when you are anything else in life. And it doesn’t take much sick to make you completely useless in life.

In my internship, we rotate every week. Every Monday – you start a new job, with a new boss. You are on your toes every second of every day, being the most flexible you’ve ever been in your life. Throw being run down into the mix of days that ALREADY run you down = hell.

This last week I drank an emergen-C every day and took at least a 2 hour nap every day and still felt dead to the world.

So anyway. It’s been almost a month of this cycle and I can’t take it anymore. I guarantee you the fact that I now haven’t tracked my food or had a proper workout (other than running two 5Ks) over this time is not helping.

THEREFORE, this week has been declared GET BACK ON TRACK FOR REALZ week.

SO I’m going to be a good little health “nut”, take my emergen-C, eat my veggies, work out at the gym and SUCK IT UP until I am back on track and this Sunday Sore Throat parade ends.

I thought I would have more to say about the plague, but I don’t. So instead – how about some photos of what I have been doing on the “Good Days” of the plague from the last month?

life via instagram:

Did I tell y’all we bought a motorcycle? No, I didn’t think so. Well we had a very rare opportunity to buy this motorcycle for very cheap from a friend who was moving – so yeah, we own it now. Today Matt and I rode it together, on the actual road, for the first time! We road down a local biker bar and had lunch, then came home. It was QUITE different than what I thought riding would be like. I can’t say I’m in love, considering I could only see the back of Matt’s head the entire time.

I am addicted to this Android Phone game called Boney the Runner. Essentially, Boney is a skeleton who is being chased by these dogs. It’s fun, I play it daily, and yes – I am 27 years old, thank.you.very.much.

This week, I was filmed for two different elementary school nutrition education videos that will be going on a school district’s website. This was a first for me! I’ve done vlogs, but those were nothing compared to this experience. Abby (the other intern in this photo) and I wrote both scripts then we had to memorize the lines we wrote for ourselves, which is not easy people. Not easy. I played a Chef, Abby played a scientist and the RD for the school district is also a chef, so she played herself!

I feel like I did a horrible job in the videos, stumbling over my words several times, but I guess we will see once they are edited and published!

In addition to running Cowtown last weekend, I ran the Be The Match 5K this weekend with some of the interns and our oncology preceptor. This race supported the Be The Match Bone Marrow Transplant Donor Registry, which I talked about in my Bone Marrow rotation recap. We all signed up to be donors and had our cheeks swabbed to be on the registry list – which is SO exciting.

The race was FREEZING. It was 32 degrees at start time and the wind was insanity. I was so cold the entire race that my lower body was completely numb. But I’m glad we all went out to support a cause near and dear to all of our hearts! I love my fellow interns.

Last week, a few interns and myself attended the North Texas Spring Seminar – which is put on by all three dietetic associations we have in the area. My former mentor Robin Plotkin was speaking, which was SO FUN to watch her speak and catch up with her. We’ve been too busy to see each or talk very much lately. We also participated in her activity – which was to make a “pin board” of our eating philosophy, practices and teachings. The interns and I had such a good time and really enjoyed adding all our favorite foods to the board!

I’m past all my clinical rotations now (recaps are COMING I PROMISE), so I’ve had much more time to read – which is mucho amazing for me! I’ve read some really good books lately, so I can’t wait to do another favorites post once I have enough to discuss! As always, you can follow my book reading on Goodreads if you want.

Somehow I stumbled into this – but if you like Reeses – 1 container vanilla greek yogurt, 2 T PB2, 1 T chocolate syrup. 17 grams protein. You’re welcome.

SO who is ready for GET BACK ON TRACK WEEK FOR REALZ? I’ll be posting everything I eat on my food blog until I am back in the good graces of my health and weight loss. Feel free to join me over there!

Another internship recap! Like I have said before, I have a lot of pediatric rotations this semester. Here’s another one for you!

We had one week in an outside Children’s Hospital – where we were assigned to various departments. I ended up being placed in the outpatient GI clinic – where the RDs see the patients right after the doctor’s visit. All the patients that come to this clinic have either some sort of GI problem, a problem with their growth, or a developmental delay/disease that impacts their oral intake.

A lot of the children that we saw in the clinic are tube feeders and have G-Buttons, which is a children’s version of a G-tube. These children have their formula and feeding schedule managed by the RD – which is tricky compared to an adult tube feeder. Children are obviously growing, so their formula intake has to be adjusted fairly often to accommodate their growth. Plus for those children that can eat orally, the oral diet needs to be considered when making the tube feed recommendations.

Here’s a random example of a little guy with a G-Button from google.

Also, there are a ton of children who are tube feeders and have malabsorptive disorders or food allergies, so they have to be on special hydrolyzed or completely broken down amino acid formulas. They have a formula room where they have samples of a TON of different formulas. We made recommendations to parents about formulas, handed out samples, and problem solved selecting new formulas for patients based on their condition/problem.

Like I mentioned, after the children and parents visit with the GI doctor – they are seen by the RD. Not every patient is seen, so basically the RDs see people as needed all day. You have about 5 minutes or less to prepare yourself for seeing the patient and parents. This includes reading their chart, calculating their needs and often calculating their current feeding regimen (in the case of the babies on formula or breast milk) and the tube feeders on formula. Then you have to find time to chart on the patients, call back parents who call with questions – and call parents who may have missed the RD for some reason while they were in the office. These ladies are BUSY!

In addition to calculating nutrition needs and the current regimen, we would plot their growth on growth charts and access whether the child was growing properly. We also calculated their fluid needs and made recommendations to the parents, especially for water flushes necessary with tube feeding. All of these factors played into the final recommendation we provided to parents.

Because not everyone was a tube feeder, I’ll give you a few examples of other patients we saw. We saw a lot of Failure to Thrive who were on an oral diet, some constipation, some weight loss, some food allergies – both in infants and children. We even saw some special genetic disorders that had complications involving the child’s nutrition status. We also provided samples of oral nutrition supplements – like Pediasure, Boost Kid Essentials, etc. The RDs have handouts for parents too for calorie boosters, nutrition content of certain baby foods, etc that parents can use to increase the nutritional intake of their child through regular food.

I will tell you, the parents of these children are on their games – especially for the genetic disorder patients. A lot of times, it would feel like the parents knew almost everything about the nutrition implications of the genetic disease. These RDs have to be very flexible and work with the parents based on many different factors.

In total, there are 3 RDs in this clinic. They also cover the inpatients in the hospital who are seen by their GI doctors, so I did have the opportunity to see 2 inpatients, which was a brand new experience for me! We saw babies that were only a few months old, to children who were 15-16 years old. Quite a wide variety of ages and patients!

Overall, it was a fascinating experience! I always thought that I wanted to work in pediatrics because I really wanted to work with parents – but after this rotation, I realized that parents don’t have an hour at a time to sit down and have an in-depth counseling session regarding their child. Maybe that works for some patients in a private practice setting, but our visits were lasting between 5-15 minutes at a time for the most part. I’m not saying I won’t work in pediatrics, but this rotation really exposed me to a much different area of pediatric nutrition that I hadn’t ever thought about.

I will say, I’m SO glad I had the NICU before this rotation. In the NICU, I got comfortable calculating pediatric nutrition needs and formulas. I definitely leaned heavily on that knowledge in this rotation – but learned some new ways to do things as well!

I really enjoyed this rotation and I am definitely learning more about pediatrics as I move through these rotations. I know some people definitely don’t like pediatrics. I’m still unsure at this point. I came into the program thinking that I would DEFINITELY be a pediatric RD, but I have really enjoyed taking care of adults. I am very happy that my program has so many pediatric rotations, because I’m going to be well prepared if I do decide to go down that route one day.

Can I answer any questions about this rotation?

Hola.

Y’all know I love a good challenge. Y’all also know that I’ve been working really hard on getting back into the losing weight mindset – especially by getting my butt back into the gym and making fitness a priority.

Truth is, I’ve done a GREAT job of this since my original post a month ago (today actually!). I’ve started running again, outside of my monthly 5K races, and I’ve worked out an average of 3-4 times a week over the last month. Cardio up, y’all!

My last 5K time

But where I still lack is with my strength training. I have mentioned this before, but I’ve definitely lost my tone and big ole muscles from the summer – simply due to a lack of time and energy. My favorite method of strength training is mixed cardio/strength boot camps – which I can’t attend right now due to a different schedule every day.

While I haven’t lost ALL my muscle, my regular tone is definitely gone. I’ve been whining and groaning about this for months – feeling like I can’t do anything about it right now and hating myself in the process. I’m getting back to that time where I hate how I “look”, especially in my work clothes. This is also related to the fact that I’m in between pants sizes right now – but that’s another story for another day.

Wearing size 12 jeans for the first time in ~10 years

Today’s post by my bestie Kristina inspired me to make some changes – specifically with my strength routine. While I doubt I can get as toned and muscular as I was at the end of the summer, I can definitely work to lose any MORE muscle and hopefully make a little progress in the process. So after some discussion with Kristina, I decided a good ole’ blog challenge is in need.

5 Week Strength Challenge

Runs:

2-11-13 (so yesterday) to 3-18-13

I’m choosing 5 weeks because I have 5 full weeks until my spring break – so I figure this is the perfect “initiation period”.

The rules:

*1 strength workout a week – either a video (Jillian Michaels, etc) or a create-your-own mixed cardio/strength workout (from my books)

*100 pushups per week (to be done on my stairs on an incline)

The prize:

If I hit ALL of these 5 workouts and 5 weeks of 100 pushups, I’m going to buy either a new purse from DSW/Zappos OR new flip flops from Zappos – tbd

BONUS:

If I bump it up to 2 strength workouts a week (plus the same pushups) – I’m going to give myself the purse/shoes AND get my car detailed.

In theory, I’m way way way more motivated to get my car detailed than I am to buy myself a purse/shoes – so I’m making that the “reach” prize. If you spent as much time in my car as I do, you’d understand the desire to get your car completely cleaned by someone else.

Tonight I already hit my 1 strength workout for the week, so in theory – I just have 100 pushups left. But I’m really motivated to get that car detailing, so I’m going to hit another workout as well this week.

Anyone who wants to join this challenge is MORE than welcome. Feel free to challenge yourself to whatever you want to do for the next 5 weeks. If you want to join – please let me know in the comments what your personal challenge and prize will be

Happy lifting!