di: rehab

Week 3 is under my belt! It was SUCH a hard/draining/crazy week, but I loved it and can’t wait to share some of the information about it with y’all.

As per my usual disclaimer, I have to be VERY confidential about what I talk about regarding my internship. I can’t take any pictures and I can’t provide any patient details.

I never considered rehab an area where dietitians would work, so I didn’t really know what to expect in this rotation. The pre-rotation homework filled me in slightly with what we would experience, but definitely not for how emotional this rotation would be.

The rehab hospital where my rotation was has approximately 75-90 patients, who are experiencing a wide variety of diseases. All the patients must participate in at least 3 hours a day of rehabilitation – from physical therapy, occupational therapy, speech/language therapy and recreational therapy. Most patients had experienced a traumatic brain injury (TBI), spinal cord injury (SCI), stroke (CVA), amputation, orthopedic surgery and/or recovery from debility from trauma or other complicated and/or awful medical course. With such a wide variety of disease states, it was definitely a challenge at first to get acquainted with all of them and how these diseases would impact the nutrition of these individuals.

I’ll run over some of the main nutrition concerns with each disease, so you know some of the nutrition interventions I worked with this week.

Overall, we had a lot of tube feeding patients – both through nasogastric (NG) tubes and percutaneous endoscopic gastrostomy (PEG) tubes. I also saw some gastrostomy (G) tubes and jejunostomy (J) tubes as well this week. These patients come in on continuous feeds most of the time, and we work to move them to nocturnal feeds and/or bolus feedings so they can better participate in the therapy and have a little more freedom. If the patients are moving to a long-term rehab facility (where they might do 6-8 hours a day of therapy), they must be on bolus feedings – so we work to get the patients to there.

Also we have a LOT of dysphagia patients, which means they have difficulty swallowing and may aspirate (or have food/liquid move into their lungs). The hardest thing to swallow is actually water, as it’s too thin for the muscles of the mouth and throat to control for patients with dysphagia. Therefore, these patients will be mainly tube fed since most have a NPO, or nothing by mouth order. Some of the dysphagia patients will be on modified texture diets with thickened liquids too. We did a lot of work moving patients from tube fed, to modified texture, to eventually regular texture diets – although this decision isn’t up to us, it’s up to the speech-language pathologists that work at the hospital.

And finally, we saw a lot of wounds – both pressure ulcers and sometimes problems with amputation wounds.

• TBI: some of these patients may come into rehab still on a ventilator, or still with a trache, if they came off the vent in the acute care hospital. If they were vented, they were on tube feedings, usually through a NG tube. Oral feeding can be difficult because these patients tend to be very impulsive or easily distracted. They may also have dysphagia, gastrointestinal problems or problems with high blood sugars.
  
• SCI: these patients are historically underweight right after their accident, with a high chance of becoming overweight in the future due to quadriplegia or paraplegia. Most have a low muscle mass and are malnourished from losing so much muscle. They are at high risk for pressure ulcers, have problems with dysphagia and usually have problems with constipation. Most SCI patients were on a bowel med regimen and may even need manual bowel evacuations daily.
  
• CVA: Self feeding is a big issue here, as is dysphagia. Depending on where the stroke was in the brain – chewing can be an issue too. Sometimes the area of the brain that initiates swallowing is impacted and these patients will never be able to return to oral diets.
  
• Amputations/Orthopedics: I’m going to put these together, because it’s a lot of wound care and a lot of higher protein needs for the wound care/bone healing.

Of course a lot of these patients had traumatic accidents, which caused these diseases – so there’s also overall healing and weight loss often from the trauma as well. I saw a lot of car accidents (both car hitting car and car hitting person), sports injuries, diving accidents and freak accidents/medical conditions that you never could have predicted/prevented.

Overall nutritionally we did a lot of encouraging and educating patients to eat more calories and protein. We recommended/wrote orders for a lot of nutritional supplements – some for just protein/energy and others specifically for wound healing or blood sugar control. Because some patients will be in rehab for months at a time, they get “menu fatigue” and just get tired of eating the food on their trays. We worked to liberalize diets as much as we could, to simply encourage the patients to eat more of the foods they wanted.

I didn’t do anything too complicated, though I did calculate some tube feedings. I calculated fluid needs for one patient, which was really awesome. Usually the doctors calculate the fluid needs, so I was happy we were able to, then sent it to the doctor for confirmation.

As for my cross-training, I watched a Flexible/Fiberoptic Endoscopic Evaluation of Swallowing (FEES) study done by the Speech-Language team. A endoscope was stuck in a patients nose and maneuvered so the tip with a camera sat just above his larynx or voice box. The team gave him foods, ice and water covered with blue dye and we watched him swallow and determined if the food/liquid was going into his lungs or down his esophagus into his stomach.

We also saw a vital stem treatment on a dysphagia patient by the speech-language pathologist. This sends electrical impulses to the affected muscles in the throat to help them start working again. The patient swallows ice chips and/or water during the treatment as much as they can to help the muscles work and receive the full benefit of the electrical impulses.

Finally, we tasted a pureed tray – which is the easiest consistency of food for a dysphagia patient to swallow. It wasn’t the tray above – ours had beef with gravy, mashed potatoes, carrots and pineapple. We tried nectar thick (the thinnest of the thickened liquids) cranberry juice, iced tea and milk. Last we tried honey thick (the middle of the thickened liquids) cranberry juice, iced tea and milk. The thickened milks were SO HARD to try, but I did it, albeit with a spoon.

The week was SO emotional for me. We spend so much time in school studying diseases that can for the most part be prevented, so intervening nutritionally in these mostly post-trauma patients broke my heart at first. It may not seem challenging to feed these patients, but it challenges your soul to be a positive force for them. I was consumed with whether people would return to normal life – like walking again, regaining normal brain function, etc – that I didn’t even care at first about their nutrition (or my job?).

I realized after A LOT of self talk and soul searching that most of these patients had come to terms with their injury by the time they are in rehab, so it’s not my place to be down about their injuries. I am there to be a positive force for them and to give them everything that food provides for people, beyond nourishment.

The RD who I worked with said over and over how she loves to see the patients get better as they work through rehab. She loved developing relationships with them and watching someone who came in NPO and on a feeding tube eventually advance to a regular diet and gain their eating independence back. While that doesn’t happen for every patient, it does for many of them.

I could go on and on about the emotions of the week, but I’ll leave it at what I said. I learned SO MUCH about myself and about what being a clinical RD means. I also learned that being a RD and helping someone be healthy doesn’t always mean the typical things we all in the healthy population think it does.

I loved this rotation and I would love to work as a rehab RD. Call me crazy because it was my first clinical rotation, but I loved how the job challenged me to be more positive and to be a leader and provider for my patients. It was so emotionally trying, but it also was so emotionally sweet to see some of the patients improve significantly in just the 5 days I was there. When you do 3 hours minimum of therapy every.single.day, you make improvements and see results very very quickly.

What questions do you have about rehab RDs that I can answer for you?