Two New Rotations, Plus Lots and Lots of Turkey

A lot has happened since I've last updated.  Let's see what I can remember...

The Week of Thanksgiving:

I spent one day with the RD that counsels patients with Continuous Ambulatory Peritoneal Dialysis (CAPD). People who have failing kidneys need alternate methods to filter their kidneys in order to stay healthy.  There are 3 ways to filter the kidneys (generally speaking). One way is hemodialysis.  This is what you might be most familiar with, where people go to centers and hook up to a machine for 3-4 hours, 3 times a week.  The second method is sort of a continuous hemodialysis, where a patient is hospitalized and hooked up to the machine 24/7. This is for the most severe cases.  Lastly, there is CAPD, where patients hook up a tube to a port that is created in their abdominal wall, put in a "clean" solution into their abdominal cavity,  waste is filtered into solution from the surrounding abdominal organs, and then they hook up a tube to excrete the "waste" solution.  This is crazy to think about, considering there is basically always solution sitting in these patient's abdominal cavity when they are living their daily lives.  So, I spent a day with the RD that talks about the nutrition issues with these patients.

For the next two days, I shadowed the transplant dietitian.  She sees patients before and after transplant procedures, talking about what they can and cannot eat.  It was a good experience, but my "week in transplant" was cut short due to the holiday.

Thanksgiving:

On the day before Thanksgiving, we had a Thanksgiving dinner at our apartment. A few of me and my friends didn't get the chance to go home for Thanksgiving, so we thought to try to have our own "family" dinner.  It turned out pretty well!  I made Cauliflower Gratin that was a hit!  Props to my sister for giving me the recipe.  Here it is if you want it: http://stickygooeycreamychewy.com/2009/12/12/cauliflower-gratin/

On Thanksgiving day, Justin and I spent our day with some members of the Boston Symphony Orchestra. It was a little awkward, especially the part where we had to go around the table and say what we were thankful for, but it was good all in all. The food was AMAZING. All I remember is these figs stuffed with feta cheese, wrapped in prosciutto, covered in some indescribable sauce.  Yum!

Since Thanksgiving:

Since Thanksgiving, I've been in the Outpatient rotation. This is where patients go for nutrition advice when they are not hospitalized. Most of the patients that I've seen so far are in for weight management, mostly overweight and obese patients.  I have seen some interesting patients such as a lady with a protein allergy, someone with Celiac's disease, a young girl trying to gain weight, and finally, a crazy mom trying to get her pre-teen to lose weight.  Yes, I will explain that last one in more detail!  So, this mom comes in and says in front of her daughter, "My daughter is too comfortable wearing her bathing suit around other people, she just doesn't care that she's fat."  Mind you, this girl is 12 years old. Still growing, still a sponge soaking up everything around her. STILL CAPABLE OF DEVELOPING AN EATING DISORDER.  Anyways, to make a long story short, let's hope the best for this young girl.

I've seen diabetics, patients with Cystic Fibrosis, and tomorrow I'm going to see some kids with stomach problems, basically picky eaters and allergies. I counseled my first patient on Tuesday.  It was kind of nerve-wracking, but the woman I counseled was the sweetest lady and said that I would do really well in my field!  She was too cute and I really think I gave her some great advice!

I will be in outpatient for the next 2 weeks. I have to counsel 5 more patients on my own......and then, Christmastime!! Speaking of Christmastime, Justin and I usually make a Gingerbread House every year. This year, my sister bought us something different.  A Rice Krispies paint-your-own house set.  See the pictures for our adventure. Note: Do not judge the house that I painted. It is HIDEOUS, I'm aware.  Things weren't working, so I intentionally made it tacky, I swear!

Two weeks from today and Justin and I are heading home for the holidays. We are both really excited!

Oh!  I forgot to mention. I met with the director of our program. She asked me how I thought I was doing in the program and I said "I'm doing okay.  But I'm doing the best that I can.  Sometimes I can be a little to hard on myself."  And she replied, "Well, I think you're doing better than okay. I think you are doing very well."  But she also said, "You are way too hard on yourself and you need to be much more confident with the amount of knowledge that you carry."  Wow!  This was such a major win in my book. I know I have the confidence issues going on, but I didn't realize I was doing so well!  I'm glad that all this work is paying off.  It's really hard to push yourself when you work yourself really hard and don't get to hear feedback like that very often. But it is much appreciated and definitely a push to keep working hard.

Last thing, I haven't posted about new nutrition stuff in awhile, but I wanted to discuss Greek yogurt for a minute. I've just started eating it and I can't say that I'm in love with it yet (I think it's going to be an acquired taste/texture for me.) But it's definitely turning me off of the low fat non-Greek yogurt that I usually buy. Greek yogurt has twice the amount of protein as other yogurts!  I think that the honey flavor is the best that I've tried.  I must admit, one of the biggest things we see that can be adjusted in a lot of people's diets is adding some protein to breakfast.  Getting protein will help you feel fuller longer. Think: not overeating later.  I'm reading a new book about mindful eating that I hope to mention about in the next post.

Happy Holidays!

The End of a Great Week!

So, my week in research was 100% fantastic!  I loved every minute of it. I did a lot of different things while in the rotation. I practiced measuring skinfolds, which is an extremely difficult skill, if I must say so. Also, I took hip and waist measurements on some patients, which is undoubtedly an extremely awkward task, but I guess you eventually get used to it.  I also took some basic heights and weights. Here is a picture of me getting the height on one of the other RDs in the office, for practice. And yes, I have finally met a male dietitian, a rare occurrence in this field!

Also, during this rotation I had to develop a diet in the metabolic kitchen. In a lot of the studies done at this research facility, they use "weighed diets". This is basically a really precise diet, where the food is weighed out to the gram so each participant receives exactly the same amount of calories, protein, fat, and carbohydrates. It takes months to develop some of these menus because there are usually a ton of restrictions. As you can imagine, it is very difficult to try to estimate everything in grams, since we Americans don't think about our food in the terms of grams, rather cups or tablespoons.  My project was to develop a one day menu. It was very difficult, taking me about 3 hours to tweak it on the computer so it was just right. For my dinner entree, I chose spaghetti noodles with sauce and shredded mozzarella cheese.  I then had to request food from the hospital kitchen to reproduce my meal. I ended up with exactly what I ordered, spaghetti noodles and sauce. But the kitchen didn't have mozzarella cheese, rather they only had grated parmesan cheese. When I had to substiute 28 g of shredded mozzarella cheese with 28 g of powdered parmesan cheese, I ended up with almost 3/4 cup of parmesan cheese. This is a ridiculous amount of cheese and if you know me, I don't even like parmesan cheese, so this was an interesting predicament.  Our assignment then required us to eat the food and weigh the tray after we ate to determine exactly how much we ate (I told you it was precise!!).  Needless to say, I had a lot of parmesan cheese left!!

The next thing I learned was how to try to use Dual-Energy X-Ray Absorptiometer (DEXA).  This machine measures the density of your bones. It can examine your entire body or just certain parts, such as your hip, your spine, or your forearm.  The machine spits out some numbers that you can use to determine whether or not you have osteoporosis, osteopenia (at risk for developing osteoporosis), or healthy bones.  I was able to get a full body scan while in this rotation, and I'm proud to say that I have no signs of osteoporosis or osteopenia!  You have to be certified to use this machine and to examine the x-rays.  But the RDs let me try it out.

Finally, the last thing that I was able to do is talk to study participants!  Some people come in with food diaries and the RDs have to go over what the patients have eaten over the past couple of days.  This is always interesting to me because I love to hear what people eat everyday.  Also, in the Research office, they have a ton of awesome food models that you get to use to discuss portion sizes. These are expensive but really helpful for the patients.

All in all, I had such a great week!  During our internship we get to choose a rotation that we really enjoyed and get to spend an extra 6 weeks there. Of course there is a project involved, but it is a really good chance to really get a feel for that career path.  I've already talked to the director about choosing Research for my concentration! I'm really hoping it will work out.

Tomorrow, I will be starting in Renal and Transplant.  I'm supposed to get a full week of this rotation, but because of Thanksgiving, I will only be getting 3 days.  I hope it goes well!  Apparently one of the dietitians in this rotation grills you with questions.  So, I'm pretty nervous. But I'll keep you updated!!

Reunited with My Love, Research

So, I just finished ICU. It was a hectic 2 weeks. I went to the conference that I mentioned in the previous post. It was pretty epic. The expo was awesome; I think I ended up with somewhere around 25 free protein bars (Luna, Odwalla, SlimFast, you name it!), lots of bags of pistachios, 6 single boxes of cereal, cranberries, nuts, and lots of other health foods of varying sorts. Every single food company you could ever dream of was there, Coke, Pepsi, Hershey, USDA Beef, Welch's, etc. And then there were new companies and foods. I tried some sweet potato chips, carrot cake frozen yogurt, vitamin drinks, a ton of new vegetarian products, etc. I went to some really good lectures and then some really boring lectures. But all in all, it was a pretty good experience.

Here is a picture of  my good friend, Kate, another intern in the internship, and I at the expo with the Laughing Cow. Tony the Tiger was there too!

During ICU, I was exposed to a lot of different things. Basically, I saw a ton of patients that were intubated, heavily sedated, and needed tube feed recommendations.   I saw patients who were severely burned, in near-fatal car crashes, overdosed on drugs, and in several other depressing situations. I've seen patients' families learn troubling news and seen patients discharged home.  It was a crazy two weeks that was ended with, what else, but ANOTHER PRESENTATION!  Yes, I had another presentation. I had to present 4 patients that I saw during ICU and present a recent research article on one. It was in the style of a roundtable. So, I had to sit at the head of the table and talk about my patients and answer a slew of questions. It went really well, considering this is considered one of the hardest rotations. I'm glad to be pretty much done with Clinicals!!

(Side note: While I was presenting, a couple of the other interns were giving tours to prospective interns. Apparently, the interns brought the students over to the window of the room that I was presenting in and told them "This is an example of one of the presentations that you will be doing if you get into our program."  One of the students replied, "It looks so scary!" I love this story.)

Today, I started the Research rotation. It was amazing! I'm so glad to be reunited with research!  (I'm a nerd, I know.) Today, I saw a couple of patients get bone scans and skinfold measurements. I also got my resting energy expenditure (REE) measured. According to the test, I burn ~ 1212 calories per day when I'm just "resting" or laying down.  For the test, I had to lay down and put a huge bubble over my head and lay down for 20 min and just breathe normal. Sorry, there are no pictures for that...

I love research so much!  I am really going to enjoy this week, I can already tell!!!  I will be getting my bone scan tomorrow, I shall report the results soon!

Intensive Care Unit is Pretty Intense... Well, Sort Of

Ok, so I've been awful at updating this thing!  Here is a recap of my last 2 weeks in my surgery rotation that I just completed last Friday!

10/18-10/22 Surgery Week One
*Oriented myself to the Phillips House surgical floor. This is my FAVORITE floor in the hospital. It's on the 22nd floor and it is exclusively private rooms. If you go to the solarium, you can see almost all of Boston.  I love this room. I will go here on my break and get lost in the view.  Sorry I don't have any pictures of it just yet, or I'd show you...
*Performed some educations on post-op surgical diets. Liquid diets for esophagus surgery patients. Low fiber, low fat diets for intestinal surgery patients. Proper nutrition for ostomy patients.
*Watched a swallow study!!  Dietitians work closely with speech pathologists.  These are the people that determine whether or not patients can adequately swallow by performing swallow evaluations. Basically, the study that I watched used a camera that was placed through the nose to the top of the back of the mouth.  The patient was then asked to eat/drink a variety of foods that were dyed with blue food coloring so we could see the substance being swallowed.  They record video of the patient swallowing the foods on the computer and then will review what the patient is allowed to eat-- only thin liquids (watery liquids), nectar-thick liquids (honey), etc.  Very exciting!

10/25-10/29 Surgery Week Two
*Basically acted as an RD and functioned as staff relief for my floor.  It was pretty exciting and stressful at the same time. I got to see a lot of interesting things such as: a gastric bypass surgery gone wrong, pancreatic cancer, heroin abuse, brain tumors, etc. Not all things had to do with surgery but they were interesting and rewarding, nonetheless.
*The rest of my week was basically consumed by my preparing for my presentation on pancreatic enzymes and pancreatitis. I did really well on the presentation and received really great feedback! Good story: I practiced my presentation in front of Justin the night before I performed it. The next night, after I had done my presentation earlier that day, I got to witness Justin explaining to a friend how pancreatic enzymes work. This might be one of the best moments of my life. No joke. He then attempted to explain the Whipple procedure, which was so awesome because he was so excited about it.  (Basically it is a procedure that is performed when a pancreatic mass has been detected. The surgeon removes the portion of the pancreas containing the mass and then cuts the bottom of the stomach to attach it to a point further down the intestine. By moving the opening of the end of the stomach further down the intestine, you get less complications of the now malfunctioning pancreas, but it often causes malabsorption of fat and weight loss. Very complicated, but very interesting.) Fun fact: Steve Jobs (Apple guy) had this done and it is why he is so skinny. Here is a picture of the outcome of this procedure:

I'm sad to be done with the Medicine and Surgery rotation. But don't get me wrong, it was one of the most exhausting things that I've done in a while.  My typical schedule was:

6:00a - Wake up, get ready, eat breakfast
7:00a - Catch train to work
8:00a - Work
6:00p - Catch train to go home
7:00p - Home/eat/take break
9:00p - Read, work on project
12:00a - Sleep

Yes, I typically work 10 hour days, only get a 30 minute lunch break and no pay.  Why am I doing this again?

Anyways, yesterday and the Monday prior, the interns and I attended a workshop at Children's Hospital in Boston.  It was all about pediatric nutrition.  It was a great 2 days and I'm really glad that I attended. I learned a lot about breastfeeding nutrition, baby formulas, pediatric intensive care nutrition, and special needs infants. It was awesome!

This week I started my Intensive Care Unit rotation.  This rotation lasts 2 weeks.  Today I was oriented to the Burn Unit.  Words cannot describe what I saw here.  Very intense, depressing, overwhelming.  I really enjoyed the atmosphere here though.  It was surprisingly calming.  Briefly, I saw a 24 year old patient today with 80% of his body covered in 3rd degree burns, he was flown in from another state after he lit himself on fire.  He was put on a feeding tube that is providing him with ~2700 kcal and basically enough protein for a wrestling team. He has such high caloric and protein needs due to the extensiveness of his body breaking down his muscle in attempt to reform the skin that is missing.  I think that is all I can really say about that for now.

Now for happier things...Last weekend I ran a 5k with my friend from Joslin and a fellow intern.  I finished in 28:00. Not my best, but not my worst either! We got cheesy medals and free beer after finishing the race.

This weekend, I will be going to ADA's FNCE (pronounced Fence-eee).  This is an acronym for the American Dietetic Association's Food and Nutrition Conference and Expo.  It is held every year and happens to be in Boston this year. Convenient, right? It starts this Saturday and lasts for 4 days.  It is a great time to network and meet with other interns from all over the US, meet RDs, and attend lectures. The guest lecturer this year is Anthony Bourdain!  Google him if you don't know who he is. Also, MGH is having a reunion for all the previous interns.  So, I will be going to that (did I mention that I am in the 101st class of dietetic interns at MGH?)  Hopefully I will meet some great people here (and establish connections for future job opportunities!!)

So, that is what is new. I have yet ANOTHER presentation next week.  It's funny, this internship only requires 8 presentations during the entire year-long program yet I have 3 within the first 2 months. Oh well!  After this next presentation, I am set until after Christmas, as far as presentations go...

A New Week, A New Rotation

This was such an exhausting last 2 weeks, sorry it's been so long since I've updated!  I had to do a 10-pg paper and a 20-min presentation last week.  My presentation was called "Hard to Swallow: A Case of Altered Mental Status, Dysphagia-Related Nutrition Support, and Guardianship."  Sounds exciting, yes?  The presentation went well overall.  I'm so glad to be done with it, a huge weight has been lifted.  I was getting 4 hours of sleep...it wasn't good. But its over with. And it is considered one of the most difficult presentations of the semester, so I'm glad to mark that off my list.  Did I mention that my presentation was video taped and I have to watch it and evaluate myself?  NOT EXCITED.

Now I am in my surgery rotation. I'm with the same preceptor, just a different floor. I've only gotten to talk to 1 patient so far, as I only started my rotation today.  The patient was a man that just had part of his pancreas removed and some re-routing of his intestinal tract. After patients have surgery that involves their intestine, it is recommended that they consume a post-surgical soft diet. This is a diet that consists of easy to digest foods such as simple carbs and protein.  High fiber and high fat foods require more effort for your body to digest, so these types of food are avoided initially after surgery (usually ~10-12 days).  We went to talk to the patient to see if he had any questions about this diet restriction, since he was going to be discharged soon and still had a couple of days to go on his post-surgical diet.  He and his wife were so lovely!  He told us to talk to his wife, since she is "the boss."  She only had a few questions, but then we realized her daughter-in-law is an RD, so we ended up talking about that more than her husband's diet!  They were just really great people and being around them really made me miss my family. I wish all patients were so easy going and easy to talk to!

Me and some of the interns decided to go to Oktoberfest here in Boston for a study break 2 weekends ago.  That was pretty exciting, but ridiculously crowded!  It was in Harvard Square.  Here is a picture from that:

Also, I took a couple of pictures while I was at the hospital.  Here are the patches that we where on our left lab coat sleeve, which we are in charge of sewing on by the way.  This is so everyone in the hospital knows we are students, I guess. Note: I didn't realize that the symbol above "Dietitian" said MGH until about 5 days ago.  Oops.

Here is a picture of me in my lab coat!  Justin takes me very seriously when I wear my lab coat, so I'm glad I really do have more authority when I wear it! This picture was taken in our intern "office."  It's very small and is crowded when we are all trying to access our lockers.

Well, that is it for now.  I don't have anything else that is new and exciting going on right now. I have another project due next Tuesday about Pancreatic Insufficiency that I'm actually really pumped about, so I'm going to be starting that soon.

Oh!  I forgot to tell you.  I found out something the other day.  So when you get a Bachelors in Dietetics, to become an RD, you know how you have to do an internship, right?  Well, 10 years ago about 75% of students got into internships that applied. Well, they just released the data and only 50% of the students that applied to internships were matched with an internship. It's so competitive and it's only getting more so.  I am so thankful that I got matched!

I think I'm going Vegetarian.

Two posts in one day! I couldn't ignore this article that I read just now. You should check this out, if you are interested in what is really in those "Chicken" McNuggets at McDonalds.  Brace yourself...

Pre-McNugget "Meat"

Should I become a vegetarian or should I swear off McDonald's?  I'm not sure, but I will keep you updated. This picture says so much about the current fast food industry.

Are you a "4th Mealer" and completely unaware of it?!!?

Time is flying and I can't believe that at the end of this week, I will be halfway done with my Medicine/Surgery rotation.  So what has happened recently?  Well, I started talking to patients on my floor without my preceptor standing over me.  The first did not go so well, but amazingly I am building up my confidence and starting to talk to patients better and better!  This is so exciting!

Also, I had a really great moment on Friday that I absolutely must share!  A patient of ours was barely eating, probably eating <50% of her breakfast, lunch, and dinner.  But somehow, this went unnoticed by the nurses (scary, I know!)  But at the last minute, before the patient was discharged, a doctor came up to me (yes, yours truly!) to tell me that he wasn't going to discharge the patient until I assessed the patient.  Of course I started panicking.  I immediately dropped what I was doing and started flipping through the chart of this patient.  To our surprise, she was hardly eating anything. I went and talked to her (on my own!) and asked her what was going on with her eating. To make a long story short, she is depressed and has no appetite.  She has tried supplements, such as Ensure, but she just can't stomach them any longer.  When I left the room, I immediately told the doctor that we can't discharge her yet.  She was going to be released to an assisted living home where there isn't really a lot of supervision with meals.  We set it up so we could record everything that she was eating (calorie counts) and I put in my own tube feed recommendation, if she continues to not eat.  Tube feeds are one of the things that interns fear most, but they really aren't that scary!  The doctor agreed with my recommendations and she was still at the hospital today! I felt amazing.  You have to realize how great MGH is for students.  In some hospitals, Dr's don't even consider what the RD says.

So, that was my amazing moment last Friday.  I have a huge presentation next week that I am trying to find time to prepare for.  We have 4 presentations during the entire course of this 1-year long internship.  And I'm about to do 2 of them this month.  Kind of freaked out, but at least, by some miracle, we get Columbus Day off, so I can have extra time to work on it (and sleep in!)

Also, I thought it would be nice to add some pictures on here.  This is a picture of the subway station where I get off to go the the hospital.   MGH is on the "Red Line." My commute takes about 45 minutes and involves 1 transfer (each way!):

Also, here is a picture of MGH...did I mention that MGH is not 1 building, rather a small city?  All of these buildings are part of the campus.  Crazy, I know.

Other more exciting things, we had a party for one of the interns birthday this weekend.  It was so great to see everyone out of the hospital.  Also, Justin, me, and my roommate went apple picking this weekend. Can I just say that the only way that I'm staying sane during this internship is by maintaining a normal life on the weekends?! It's so good to get out of Boston every now and again!

One more thing, I recently read a study that came out of NC Chapel Hill about snacking.  In the past 30 years, the average calories from snacks have increased from 345 cal/d to 547 cal/d.  Can you say 4th meal?? Do you know how much you are snacking!!?!