It’s been a rough week-week 1/2 for me, so I’ve had to re-prioritize the things on my to-do list and unfortunately blogging was one of the things cut this week. That said, I wanted to make sure I post my last week’s internship rotation recap – because that is the LAST thing I want to get behind on. I know a lot of y’all like reading these, and I want them for my collection – so I’m making that THE priority for blogging this week.
Last week I was in the Neurology rotation – which was kind of a hodge podge of stuff. The preceptor for this rotation has all the neurology floors, but also is on the respiratory/airborne isolation floor and does some outpatient work as well. So I kind of saw a lot of different stuff last week.
As for Neurology itself, I spent most of my time there in the Neurology ICU and the Acute Stroke Unit (ASU). As RDs at my hospital, we see every single patient in all our ICUs, as well as the ASU – within 2 days of their admit. If they came to the ICU Monday, we have to see them by Tuesday end of day. So we spend a lot of our time in the different ICUs, since these patients truly need our help and their status changes so rapidly compared to someone on the floor.
On this floor there is also a Epilepsy Monitoring Unit (EMU) and a migraine section of the floor as well. Everyone else on the floor was some sort of neurology patient or a patient who transferred out of the ICU/ASU/EMU.
SO like I said – a lot of time in the ICU/ASU. Therefore, I saw a lot of post stroke patients, a lot of altered mental states, some seizure patients and post brain surgery patients. I kind of talked about the stroke patients in the rehab rotation overview – so I won’t talk about the nutrition interventions there. I will say that most of the patients I saw for all of these diseases either couldn’t speak, were confused/altered mental state or were asleep/ventilated. So I didn’t really feel like I did a lot of work with the patients directly this week – I relied very heavily on the nurses and patient charts to perform my nutrition assessments/follow-ups and intervene.
Most of these patients were either eating orally, on a modified texture diet for their dysphasia (swallowing problems), or were on tube feedings. So I didn’t do too much with diets this week – not many supplements or diet liberalizations. We mostly just kept patients on what they were eating if they were tolerating, which you couldn’t always tell since you couldn’t talk to them.
We were supposed to teach a Migraine class for a migraine tailored diet, but we only had one migraine patient while I was there, therefore we did an independent education with her. The main message of the Migraine class/diet is to avoid foods that are triggering for you. Common trigger foods are caffeine and foods containing Tyramine, which is in aged foods – cheeses, cured meats, etc.
Onto respiratory – we did a lot of pre-rotation work on Cystic Fibrosis adult patients, but unfortunately didn’t see any patients with CF. The respiratory patients that I saw mostly just were on airborne precautions or isolation, and therefore needed to be on this floor of the hospital. Every room on this floor has negative pressure air – which means the air circulates to the outside, rather than throughout the hospital vent system. This is crucial for patients who are on airborne isolation, since they need fresh air for every breath. Examples of someone who may be on an airborne isolation is someone who has suspected Tuberculosis.
I wore either a gown/gloves or a face mask to see most of these patients. There was really no rhyme or rhythm for what diseases I was seeing, though I did a lot of tube feedings on this floor.
As for the outpatient portion, this was my favorite part – which really didn’t surprise me. We spent 2/3 of a day in an ALS clinic. This was definitely the best part of my week, but also really emotionally challenging for me. The ALS patients were in all different stages of their disease and they all come to this clinic once every 3 months and meet with their entire health care team at the same time. There were doctors, nurses, nutrition, physical therapy, speech therapy, pharmacy and others (I honestly didn’t get to see who everyone was). You essentially just walk around this big open room and just meet with patients as you can, and you have to see everyone there. It’s a little crazy trying to see 15 patients while competing for charts and with all the other health care professionals.
ALS affects nutrition in a lot of ways. Patients will lose the ability to swallow, possibly chew and will usually lose their appetite or have early satiety because they become too tired to eat. Therefore have extreme weight loss and also muscle atrophy as their entire body becomes paralyzed. They have a lot of lower GI problems and all struggle with constipation by the end of their disease. There have been numerous studies that I read in preparation that show early Nutrition intervention in ALS is imperative. Some patients even receive PEG (feeding tubes that go straight into the stomach) before they have any problems with eating in anticipation of what is to come.
We would listen to each patient and tailor our counseling to the problems they were having. I spent a LOT of time encouraging protein and calories, as well as fiber and fluids to help with constipation. I had samples of oral supplements I could offer patients who have problems meeting their nutrition needs with their oral diet. I had handouts I could pass out with information on protein, high/protein calorie drink recipes and quick snacks for patients to eat. I talked to people about their tube feedings if they were on them or anticipating getting a PEG tube placed. I encouraged patients with early satiety to eat smaller, more frequent meals. I also talked to people about taking a multivitamin and other nutritional issues.
Protein is huge for this group of patients. There have been studies that show eating the same amount of protein with each meal throughout the day will slow/delay muscle atrophy in ALS patients. I did a lot of protein coaching throughout the day and calculating people’s protein needs so I could give them a goal number to hit every day.
It was SO difficult at first to be in the clinic. Some patients have lost the ability to speak and have to use iPad applications that they type into and speak for them. When I saw one patient using this, I almost started crying. This is so silly – but I thought about him using the iPad to tell his wife that he loved her, and I almost lost it in the middle of the clinic.
Thankfully I hung in there and found quite a few patients who were joking and laughing with me and their families (who were all present with them). I had one patient in particular that stole my heart away and really helped me see that I HAVE to be positive about their prognosis, as many of them are doing currently.
The clinic reminded me so much of the Rehab rotation and really just took my heart by the end of the day. As I rotate through more and more acute care, I see that my heart truly is in the rehabilitation/outpatient counseling more and more. Granted, I still have a way to go as far as the rotations, but so far – both of these rotations have changed my life and my general outlook. I really feel called to that area of practice and so far, it’s definitely at the top of my list.
The neurology part of the rotation really didn’t catch my interest. I didn’t really feel like I was able to help people, and I definitely didn’t form relationships with patients – which are two BIG things that I WANT in my career. I definitely struggled with this throughout the week, though I am learning more and more that I love calculating tube feedings and doing enteral nutrition. So, I guess that was good for me to get more practice there!