I honestly can’t even remember whether I told you anything about my 5-week medical nutrition therapy rotation at LSU University Hospital. AKA the only public hospital in NOLA and the only level-1 trauma ceenter, AKA shit. goes. down. BUUUTTT befofre I tell you about all the good stuff I’ll give an overview of the responsibilities of a clinical dietitian.
When a person arrives at the hospital, they are triaged and have to answer a bunch of questions about a bunch of different things. Among the questions they are asked is a nutrition screen. The nutrition screening questions include things like are they a trauma patient? Burn patient? Have they experienced rapid weight loss/weight gain? Nausea/vomiting/diarrhea/constipation? Trouble swallowing? These issues (and several others) will trigger a nutrition consult. Additionally, the RDs will see a patient if they have been NPO (not being fed) for 5+ days, if their MD orders a consult, or if they have been in the hospital for 8 days or more and haven’t yet been seen.
The services provided for patients vary based on their condition. If someone comes into the hospital with a stroke or heart attack, the RD will go see them, discuss their diet, and give an education about how to eat for heart health. We also change their diet order in the computer so that the kitchen sends them food that complies with the cardiac diet. The same goes for patients who come in with kidney failure: diet education on the renal diet and change the diet order. Often, people come in with complications of diabetes and have not only never been educated on the diabetic diet, but have never been told that they have diabetes. In that case, we give a short diabetes education session and often refer to an outpatient diabetes specialist, or the doctor can consult a certified diabetes educator. All of these special diets are things that any nutrition student is bored to death of, but teaching the diets can be extremely difficult, especially depending on the education level of the patient.
Other patients come in severely wasted (low BMI, not drunk people. Although we did get some of those too) and need to gain weight. Think cancer patients, people with chronic diseases. For these patients, the RD will go and obtain food preferences, put an order in to the kitchen to send them extra snacks and oral supplements like Ensure shakes. Questions are asked to figure out whether the patient is eating, why they may not be, and other factors that may be affecting nutrition status. The RD can put in recommendations for tube feedings, TPN or PPN (parenteral nutrition – when the patient is given nutrients intravenously), appetite stimulants, modifications to the diet, labs to help monitor nutrition status, daily weighing, and other things.
Perhaps the most exciting patients in the hospital are the trauma patients. Our hospital in particular gets a lot of gunshot wounds (GSWs) and car accidents (MVCs). Any time there are holes in a person’s body or traumatic brain injury, it is likely that two things happen simultaneously: 1.)the person cannot eat normally due to holes in the gut, surgery, or being unconscious or sedated; 2.) the person’s calorie requirements go way up – when your body is repairing itself, extra calories and protein are needed. This gives the RD a particularly interesting challenge: how do we get the person fed so that they can heal while not being able to feed them like a healthy person?
Sometimes, it is possible to use a tube and feed formula straight into the stomach through a nasogastric (NG) tube. The hospital has several different formulas available with different calories per mL, percentage of protein, and different types of fats, amino acids, and carbohydrates. There are formulas with extra protein for trauma patients, elemental formulas that are easy of the gut for those with injury to the GI tract, special formulas for renal diabetic and obese patients, and others. The RD must calculate calorie and protein needs, choose the appropriate formula, and determine the appropriate rate at which to feed these formulas.
Other patients cannot be fed into the stomach. This happens a lot when someone comes in with abdominal GSWs and they need time for their lacerations to heal. In this case, the RD gives a recommendation for TPN. Again, needs are calculated, but instead of choosing a pre-made formula, the RD determines how many grams of amino acids, dextrose, and lipids per liter and the rate of administration in order to reach the daily needs of the patient.
When someone is on a TF or TPN, it is essential to monitor labs for protein status and weight to ensure that the patient is getting adequate nutrients. These people generally need to be followed up on every single day whereas the diabetes/cardiac/renal patients may need just one visit from the RD. At University, there were two RDs who handled four floors, and the other two split the ICUs – one for the surgical ICU and one for the trauma ICU.
I spent my first couple weeks working with less complicated patients, getting used to counseling in a clinical setting and using the electronic charting system. The last two and a half weeks of my rotation were spent in critical care, calculating all these feedings and dong my case study.
Of course, I had to choose the most interesting patient possible to do my case study on, and without getting too detailed I’ll give you the general idea. I titled the presentation “Mardi Gras (almost) Kills: a case study of trauma in the obese patient”. My patient was working on a mardi gras float when a band saw got stuck. He tried to use a wooden pole for leverage in getting the saw un-stuck, but somehow impaled himself. The wooden stake went into the right side of his chest and was removed on-site. By the time he arrived at the ER, he had lost over a liter of blood (people generally only have 5) and was rushed to emergency surgery. Following surgery, the man required mechanical ventilation and was intubated.
This is where I came in. This man needed to be fed, but had a breathing tube down his throat. Luckily, his gut was working fine and he could be fed into his stomach. This meant he would need a tube feeding. But how much should I feed this patient? His BMI was over 50, but having an enormous open wound across his chest increases his needs a LOT. I did some research about best practices for morbidly obese trauma patients, and there is evidence best way to go is to underfeed the patient calorically, but ensure that they are getting adequate protein if their kidney function is normal (which it was). This helps reduce infection, wean from the vent, and maintains lean body mass.
I won’t bore you with more details, but I will say that I did everything possible to make my power point presentation to the class a little goofy. I know trauma isn’t a laughing matter, but we have seen so many presentations at this point that a bit of humor was definitely needed. My solution? Use paint to add some gruesome wooden stakes and blood to every mardi gras-related clipart picture I could find, and conclude it with a grand finale: a picture of four of us interns at a mardi gras parade
The photoshopping was definitely the highlight of my MNT experience. A lot of the time, I feel frustrated that the Tulane internship isn’t as serious as I had expected, but then things like this happen and I know I wouldn’t be allowed to throw a borderline-inappropriate sense of humor into my homework assignments elsewhere.
So how do I like clinical nutrition?
Eh, it’s ok. I could do it for a few years. I like walking around, seeing interesting medical cases, and reading through the notes from other medical professionals (I find I especially like the social worker’s notes – I really like getting to know people). I definitely couldn’t do it forever though. Clinical burnout is common in nutrition, especially for those of us who are interested in the person behind the condition. You only get a few minutes per patient, and that is not long enough to make friends! I have much preferred outpatient clinics where people come back regularly and you have at least 30 minutes to spend with them.
Many RDs refer to clinical nutrition as “paying their dues” before getting into other areas of the profession. Some will say that it gives them a more comprehensive understanding of different disease states that is essential for using nutrition in different populations. I am not sure I agree. After having spent just five weeks at the hospital, I feel pretty well versed and have no desire to work clinically (except for money-making purposes).