Sunday, February 28, 2016

CDE in Training

               After finishing my 10 week clinical rotation I interned at three outpatient diabetes and endocrinology centers.  I rotated at the University of Maryland Medical Center (UMMC), Baltimore Washington Medical Center (BWMC), and Greater Baltimore Medical Center (GBMC).  I observed Certified Diabetes Educators (CDEs) working with patients in group and one-on-one sessions.  CDEs are health professionals that have advanced knowledge and skills working with pre-diabetes, and diabetes prevention and management.  They work with patients to promote diabetes self-management education (DSME).  While each educator had their own style of counseling and patients had their own set of challenges and needs; I found there was one common goal to empower patients to take control of their diabetes.  Diabetes is a chronic illness with no cure, and can often wreak havoc on the body if not managed well.  Nerve damage, kidney failure, and infections are only a few of the consequences of poorly controlled diabetes.  CDEs work to teach patients how to take control before and even when some of these complications occur. 

While observing a one-on-one education, a CDE perfectly described to her patients the importance of diabetes management.  She said, "Manage your diabetes, or your diabetes will manage you."  The CDEs I observed gave their clients the tools and developed support systems that would help their client achieve their goals.  Blood glucose monitors were a main tool for clients.  CDEs often taught patients how to properly use a monitor as well as set a schedule for taking blood sugar levels.  Many patients did not understand the importance of regular monitoring, and the educators worked to show them how keeping logs of blood sugar levels can help you see what foods spike your blood sugar, as well as how well your medications are working. 
            Another tool used was different insulin delivery devices.  These include vial and syringes, insulin pens, and insulin pumps.  The CDEs I observed taught their patients how to properly use their syringe and vial or pen and used the actual devices to assure patients could do it once at home.  This allowed patients to feel more comfortable using their insulin. Insulin pumps are used mostly with type I diabetes patients.  These patients go through a lengthy process and training to assure they can properly monitor their blood sugar levels, carbohydrate intake, and insulin delivered. 
Many insulin pumps can be synced with smart
 phone apps and computers 


 The tool that I found to be universal was nutrition education.  Each patient has different food preferences, living situations, carbohydrate sensitivities, and possible other health complications.  All these must be taken into account to develop the best method for monitoring their intake.  For type 1 diabetes and type 2 diabetes requiring insulin, carbohydrate counting is key to give the right amount of insulin for carbohydrates eaten.  For other patients, carbohydrate can be used if patients are more comfortable with math and food label reading.  Another method commonly used is the MyPlate method.  It provides patients with a visual of how their meals should look.  This limits how much carbohydrate intake they have while increasing fruit and vegetable intake. 

            My time working with these CDEs showed me different ways of counseling patients and working with them to manage their illness.  Coming to my internship I was unsure the setting I wanted to work in as registered dietitian, but after two weeks I have found my passion.  So, look out world for this future CDE to be!


Monday, February 22, 2016

Outside My Comfort Zone

As an undergraduate, I had an opportunity to intern at Wellness Corporate Solutions in Bethesda, Maryland. As a Wellness Coach intern, I authored blogs, newsletters, and webinars, I attended health fairs to promote healthy eating, and I taught fitness classes to clients’ employees. I was extremely excited to have another opportunity to intern at WCS during my dietetic internship; I could reconnect with familiar faces and exciting projects. However, already being there before, it was important to both my preceptors and I that I was exposed to different kinds of assignments to get the most out of my second experience. This is how I was introduced to Positive Psychology.

I was tasked with completing an hour-long seminar subjected in Positive Psychology in the workplace. Although I had no background in the topic, I researched and read online articles to put together an outline. Confidently, I requested a meeting with my preceptor to go over what I had finished so far. The feedback was honest and constructive, however, essentially tore my draft apart, one that I had spent hours on completing. It was the first time in a long time I felt frustrated in my own work. Although I initially perceived the feedback negatively, I decided to shift my mindset to see it as an opportunity to grow. It was time for a fresh start, not a defeat.

I realized that googling “Positive Psychology” or “How to be happy” wasn’t going to cut it. I downloaded podcasts from experts in Positive Psychology from the Ted Talk Channel. I listened everyday on my commute home on the metro and in the car. I read research articles and reviewed studies. I even finished an entire book by Shawn Achor, a Harvard researcher and expert in the field, titled “The Happiness Advantage: The Seven Principles of Positive Psychology That Fuel Success and Performance at Work”.

Psychology goes hand-and-hand with Nutrition. Why people eat the way they do is an important factor in changing their food choices. I used to make excuses for myself, “I have a degree in Nutrition, not Psychology”, because it felt out of my comfort zone. I now realize that pushing myself into areas where I feel uncertain is how I will learn and benefit from these experiences the most.

The second time around, my outline hit the mark, and I was able to put together a seminar that would be taught to Discovery employees across America. I felt incredibly accomplished that I completed a product that the company was confident in, when I originally was not. Thank you Wellness Corporate Solutions for forcing me out of my comfort zone, I know I’ll be a better RD for it!

Friday, February 19, 2016

Critical Care Joint Class Day

The University of Maryland, College Park interns and other Virginia/Maryland area interns recently participated in a joint class day hosted by the University of Maryland Medical Center. We heard from dietitians about their important role as part of critical care and trauma medical teams that treat patients facing severe medical issues. 

David, Elizabeth, Meredith, me, Valerie, Mariah & Cassie
at UMMC Critical Care Joint Class Day
We heard presentations on critical care nutrition assessment, challenges in enteral nutrition, nutrition considerations in critical care, and electrolyte management. The day provided a great overview of what an RD does in a critical care setting. 

Some of the highlights:

Assessment in Critical Care 

Assessing patients who have undergone significant trauma will have drastic metabolic changes to consider. They will likely be experiencing a hypermetabolic state with elevated heart rate, respiration rate and temperature. Patients recovering from trauma may experience impaired ketogenesis, catabolism of lean body mass, increased protein excretion and negative nitrogen balance. Needs should be calculated carefully for both energy and protein using indirect calorimetry, if it’s available, or the appropriate predictive equations. 

Challenges in Enteral Nutrition

Patients who fall into the “critical care” category have undergone significant injury and will likely be unconscious and possibly intubated, so enteral or parenteral feeding is needed. In critical care settings, enteral formulations generally lack sufficient protein to meet higher demands, so the addition of protein modulators help compensate. Patients must be closely monitored for re-feeding syndrome, as many patients may have gone without food over a number of days for surgeries, tests or procedures. 

Nutrition Considerations in Critical Care

There are additional factors to consider for critically ill patients that impact nutrition. Renal replacement therapy, surgical wounds with drains, respiratory support and extracorporeal membrane oxygenation (ECMO) each alter the need for both energy and protein. These supportive therapies are also constantly changing, so RDs need to closely monitor their patients feeding to ensure they are not over or underfed. 

Electrolyte Management

Managing electrolytes is an area of care where dietitians can shine. Critically ill patients (especially those in TPN), may demonstrate unstable electrolyte labs. Factors influencing electrolytes are many: TPN or enteral formulas, IV fluids, medications, renal clearance, gastrointestinal losses, wound output, blood transfusions – to name a few. Adjusting as you go may be necessary, and an RD can help the medical team better understand how these moving pieces fit together as they try to help their patients improve. 

Overall, this class day was jam-packed full of information and I learned a lot. Each of the dietitians who presented was also a CNSC (certified nutrition support clinician), and their experience demonstrated how useful that secondary certification is as part of a critical care team.

Tuesday, February 9, 2016

Turnips on the Terp Farm

Elizabeth and I had the privilege of visiting the Terp Farm last week as part of our sustainability rotation. Our experience there was both rewarding and educational. In addition to helping out with the harvest by picking out, cleaning, and packaging turnips for the 2016 Taste of Maryland Legislative Reception, we were also given a lesson on Terp Farm’s history, mission, and impact by Guy Kilpatric, the farm’s lead agricultural technician and cultivation expert.
Terp Farm, located in the Upper Marlboro Facility of the Central Maryland Research and Education Center, shares a 202-acre plot with students, faculty, and volunteers from the University of Maryland’s College of Agriculture and Natural Resources, Department of Dining Services, and Office of Sustainability.
As we learned, the goal of Terp Farm is to become a fully sustainable operation in all senses of the word. The ecological footprint of Terp Farm is reduced through environmentally sustainable farming methods, such as crop rotation and use of organic herbicides and pesticides. Guy showed us his impressive farming plan, which incorporated dozens of different crops rotating through a relatively small 2-acre plot without any overlap through a four year timeline. In addition to extensive planning and careful considerations of cover crop usage, plenty of sweat and hard work is required to maintain the health of the land. The vegetables planted in the Terp Farm greenhouses all use the no-till farming method, which is a strategy for preparing a seed bed with minimal damage to the soil. Instead of pulverizing a large amount of earth into fine particles with the use of large machinery, Guy painstakingly breaks apart clumps of dirt with a broadfork, being careful not to destroy the structure of the soil. This method not only increases the soil’s nutrient retention and resiliency, but also health and yield of the crops.
We also learned that Terp Farm ultimately seeks to serve as a “residency” program for the next generation of America’s farmers. As Guy explained, over four million farmers in the United States are within five years of retirement and need to be replaced to maintain agricultural productivity. However, Terp Farm puts a positive spin on this otherwise insurmountable statistic. By providing the training grounds for students to become prospective farmers, Terp Farm reduces labor costs while offering an immersive and all-inclusive education to those that come to work in the fields and greenhouses. This method of integration into the community results in widespread social impact while maintaining financial autonomy.

While our time at Terp Farm was short, we learned so much and were glad to be a part of this amazing and fantastic project at the University of Maryland. Consider paying the Terp Farm a visit for yourself or even volunteering for a day to get a sense of what goes into running a sustainable farm operation!

Monday, February 1, 2016

New Year, New Rotation

This year, on the first week after winter break, I started my longest rotation: clinical! I got assigned Franklin Square Medical Center. I was somewhat apprehensive, because of the tales I've heard from past interns, but mostly I was excited for the new experience! On the first day, I was fully prepared and walked in bright and early with my lab coat, calculator, binder, notebook, pens, highlighters, and everything else I could think of to prepare myself. 
400 bed hospital

My preceptor was very welcoming. She helped me get a badge, introduced me to the other dietitians, and gave me a brief tour of the hospital. I was given my own computer station, since this will be an eight week rotation (followed by an additional two weeks of staff relief, working by myself!) We started out slowly, with me observing her as she met with patients and wrote notes about the consults. She asked me anatomy and medical nutrition therapy questions, so I'm very glad I had homework and class days for review! My first preceptor and all the dietitians are very knowledgeable, and were able to list facts for every disease state we encountered. I strive to reach that level of thorough knowledge, which I know will come with more years of experience.

Gradually, my duties are being expanded and my responsibility at the hospital is growing. One of the first things I saw was how they actually decide which patients to see. At this hospital, patients are seen if a nurse asks for a nutrition consult, if a doctor asks for a consult, if a patient has been in the hospital for more than 6 days, if a patient has been on a liquid diet for 3 days, or if we are following up on a past patient. Each day, I get a printout of the patients and use colored highlighters to screen who I need to see. So far, I've also learned how to read medical charts (paper and electronic), how to decipher lab values, how to read radiography notes, and how to present a patient's history. One of the most important skills that I'm developing during this rotation is the ability to read a large amount of information and pull out which pieces are relevant to the nutrition problem, diagnosis, and interventions. For my first few assessments, my preceptor came into the room with me to observe, and she occasionally interjected if I forgot something. I was surprised by just how quickly it felt natural, and soon after I started seeing patients by myself and writing the notes alone, then reviewing them with the preceptor to make any necessary edits before she signs off on them so I can add them to the official patient chart.
An example note that I wrote after seeing a patient (no private information on this page)

So far, I've shadowed a dietitian on the general floor, surgical floor, and oncology floor. Next week I'll begin cardiology and renal. I'm really enjoying each new assignment, and my binder of notes is growing quickly! To all future interns who are nervous about clinical, don't be! Prepare yourself in advance by brushing up on your MNT, and then be excited! It is a fantastic feeling to put all your education to use, meet patients, and have the ability to make decisions that actually affect and improve their outcomes.