Going Public - Visiting “Hospital General de Puebla Sur"

Finally, a visit to a public hospital! Hospital General Sur, is the real Mexico, where the regular Poblanos go – and the difference is immediately obvious. The truth is, that Mexico is a 3^rd world country, which means that a “middle class” doesn’t really exist. In 1^st world countries such as the US, the majority of the population are “middle class.” The patients at Hospital General are generally poor, without insurance, and many times illiterate or don’t speak Spanish (they speak an indigenous language such as Nahuatl). Needless-to-say, this is a difficult population to serve.

My visit to HGS was a bit overwhelming. It only has 5 floors, but trust me – there’s a lot going on. The hospital floors are broken down accordingly:

Ground Floor – Waiting Room, Government Offices, Consultorios, Nutrition Office, etc.

First Floor – Emergency and Operating rooms

Second Floor – Internal Medicine, Artificial Nutrition, Cardiology, Therapy

Third Floor – Pediatrics and Infections (the infections area is completely separate with movable class walls so that if there is a patient with the flu or more severe infection, the entire area can be sealed off)

Fourth Floor – Surgeries and Trauma (more along the lines of bone fractures)

The nutrition department is on the ground floor and the girls that work there are amazing. I say “girls” because I haven’t met a single nutritionist (apart from Gabby, the nutrition coordinator at UPAEP) that have been over 30 years old. Proof that nutrition is a fairly new career, especially in Mexico. The department consists of 3 nutritionists, 2 dietistas (techs in the US) and 1 almacen. The almacen is the women who is responsible for the kitchen inventory – she orders the food and makes sure that all of the ingredients necessary for the week are in order. Not an easy job in a hospital that was serving 70 patient meals on the day of my visit. This position is the equivalent of “food management” in the States. The nutrition techs, or dietistas, are responsible for creating the cyclical menu – which is different for the patients and the hospital employees. I’m having flashbacks to my food management course at NYU and how to calculate the quantities of every single ingredient needed per day. I have a great amount of respect for the dietistas and the almacen. The kitchen itself is large and the staff are employees of the hotel – not professional chefs or an outside contracted company like in the lovely private hospitals.

The nutritionists have a large variety of responsibilities which include visiting all of the patients, working with doctors (“inter-consulting”) to create the diets, and communicating with the kitchen staff all of the diets per meal. Each diet is color coded to represent: normal, bland, clear liquids, liquids, hepatic, nephro, low sodium, low fat, diabetic, etc. The ladies have created a system where each diet corresponds to a colored card, which includes the “restricted foods” for that diet on the back. Each card is place on a try with patient name and room number to ensure that no one receives the wrong meal. For example, in a “Bland Diet” the following foods are restricted:

• Broccoli
  
• Jicama
• Cauliflower
  
• Beans
• Meat with cartilige
  
• Deli or processed meats
  
• Melon
• Watermelon
  
• Citrus
  
• Cucumber
• Chocolate
• Radish
• Corn
  
• Salsas (Sauces)
• Zucchini flowers
• Coffee
  

On the 2^nd floor is the nutrition office for artificial nutrition. In this office the nutritionist works on preparing the milk/formula for babies as well as the formula for the patients receiving enteral nutrition. All of the supplements (ingredients for the formulas, vitamins, liquid forms of MgSO4, KCL, NaCL, calcium, etc.) are also kept in this office. It’s extremely important to take precautions not to cross-contaminate when creating the formulas. The patients and infants receiving the formulas are immuno-compromised – so the nutritionists take extra care in this area. So the nutritionists are extremely busy working in a variety of areas to ensure that all the patients of HGS are receiving the correct nutrition. Also, I was impressed by the “inter-consulting” at the hospital. The nutritionists actively review all of the doctor-prescribed diets, and have the ability to change the diet if it is deficient in some way. Personally, I think this is the way it should be. As much as doctors know, they are not trained specifically in nutrition. This is our area of expertise, and we should be respected for our professional knowledge. To have the ability to review the diets and make the necessary changes is an excellent way to ensure that the patients are actually receiving the diets and nutritional support that is necessary for their recovery.

Just to clarify, there is a huge difference between private and public hospitals. A nutritionist working in a PUBLIC hospital encounters the following:

1. More patients to see and more direct-contact with patients. A private hospital may only have a few patients to see in a day, and often the diets are prescribed strictly by the doctors, unless an “inter-consultation” is requested.

2. A variety of complications – patients differ drastically in their conditions, diseases, treatments and needed nutritional support. Nutritionists need to be aware of how to provide the best nutrition in any number of situations, for all types of ages.

3. Patients commonly cannot read, write or speak Spanish – it’s difficult to effectively communicate to determine what is the problem and explain to them the diet or treatment. If they can’t read, handing them a pamphlet on diabetes is worthless. Somehow the nutritionists need to communicate/educate with the patients about their conditions, the foods they can and cannot eat, food processes, when to eat, quantities, variety, eating with medications…

4. The population is poor – food availability is an issue as well as paying for medications. Combine this with a low education level and all the other issues mentioned above…

On a last side-note, although working in a public hospital is a real experience, it can be really frustrating. Be careful not to let you frustrations show, or project them onto your patients. It’s never their fault if they can’t communicate, are uneducated, or any other obstacle. In this case, we are the professionals and always need to act calm, sure and in control – and to not add anymore stress to an already stressful situation. I know, “easier said than done” at times, but I’m asking you to be aware of how your attitude, words, actions or body language could possible make a patient feel more comfortable or the opposite.

As challenging as working in a public hospital can be, it’s reality for the majority of the population and those that work there. There’s a lot to learn about communicating, educating and treating patients. Overall, it’s the best and most real experience you can receive in nutrition.

Some quick tips to help you on your way:

INTERNING ADVICE

1. Be prepared to communicate in ways other than giving a pamphlet or even verbally talking –patients may not speak your language or know how to read. It’s called being “culturally sensitive.”

2. Know the demographics of your patients.

3. Be aware of how YOUR presence affects the patient – try not to project your frustrations on anyone else (patient or anyone else!)

4. Encourage inter-consultation between doctors and nutritionists – teamwork is the best way to ensure that a patient is receiving the best care.

5. Be sure of yourself – meaning don’t think that you’re unqualified or not educated enough. As long as you’re eager to learn AND confident you’ll be capable of learning how to do anything you’re asked to. It’s the truth!

Goodluck!

Visiting "La Casa del Abue"

It’s no secret that the family system in Mexico and the US are very different. Generally in the States, grandparents are not included in the immediate family, which means they don’t live with their children. Not always the case, but the truth is… nursing homes often become “home” for the elderly when they can no longer take care of themselves. In Mexico, abuelitos are highly-respected members of the nuclear family, and their health and happiness are of interest to their children. This is the primary reason behind the federal government creation of “La Casa del Abue” (LCDA) – the first of it’s kind located in Puebla, Mexico.

When I say the “federal government,” I mean the institution located within the fed gov recognized as DIF (sistema estatal para el desarrollo integral de la familia). The purpose of DIF is to promote the general health of the people, and in particular… of Mexican families. Through DIF, LCDA was created in 2006. The mission of LCDA, is to provide the elderly (over 60 years) with the tools and space to maintain a healthy, active life-style, while helping them to remain an important part of the nuclear family and community. In the US, such places are commonly called “American Legions” but only offer activities such as Bingo and board games. LCDA is a place that is both a health clinic, providing all types of medical services, as well as offering social activities – fully promoting the general well-being of the elderly (physical and mental health). It is not a place for living, like a nursing home, but a community center with medical services. 

For example, the clinical part of LCDA provides the following services: medical doctor, dentist, nutritionist, psychologist, cardiologist, optometrist, and physical therapy. However, services also include other forms of therapy including acupuncture, water-pressure therapy, heat-therapy, laser-therapy and other treatments that I am not familiar with. The activities offered are seemingly-endless. There’s aquaerobics at the pool, all types of dance classes, singing, instrumental music, board games, pilates, Taichi, yoga, zumba (VERY popular in LatinAmerica), wood-shop, baking class, cooking class reading at the library, trips to nearby locations… like I said, ENDLESS. I can’t even begin to tell you how impressed I was with everything that LCDA had to offer. The atmosphere could only be described as being fun and healthy. In the tradition of most building of Mexico, the entire activity space is open, full of natural light, and comfortable.

LCDA also has a dining hall that serves lunch everyday. The menu is created by the kitchen staff, and reviewed by the nutritionist. Karla is the only nutritionist on-staff and she also calculates the amount of calories, protein, fat, and carbohydrates for each food item. The menus are posted outside the cafeteria clearly showing the nutritional value for the day. Every meal is cooked without salt, no sugar, low in cholesterol and with very little fat. In this manner, the meals are healthy and acceptable for all people with a variety of conditions (diabetes, renal disease, heart disease, etc.) The meal for the day when I visited included: pea soup, melon water (water flavored with a bit of pureed fruit is very common in Latin America), crackers, tuna Mexicana and yogurt with granola. The meal was calculated to have 564kcals, 22.9g PROT, 13.7g Fat, 69.1g CHO.

The consideration that goes into creating this daily healthy menu is both impressive and a challenge. To create meals that limit salt, sugar, fat, etc AND taste good is no easy job. Kudos to LCDA, the kitchen staff and K. the nutritionist!

On that note, it’s important to mention how servicing the elderly population can be both demanding and challenging. In my opinion, it’s probably the most difficult population to work with for many reasons:

1. Older people have had diets and eating patters for a very long time, they are often reluctant to change what they eat or how they cook.
2. They may not be independent any longer and depend on family or other persons to cook their meals, which means we have to educate those who are making the food choices.
3. Food is a comforting part of life, deeply tied to the psyche. Asking someone who is sick, depressed, stressed or just plain exhausted with life, to change the way they eat may be asking too much. If food is one of the few things they truly enjoy, how can we justify the additional stress change may add to their life?
4. There’s the old and the very old. I can’t really imagine telling a 90 year old woman to cut-back on the cookies and cake. There’s a difference between helping someone to develop a healthier diet that will have positive effects in the future, and just being silly. She’s 90, let her eat what she wants!
5. Food safety is a HUGE concern. The elderly population is one that is immuno-compromised, which means that they can become easily sick from the bacteria in normally and not normally found in food. Not only do they become sick more easily, but it can be difficult or impossible to recover from a sickness. Without a strong ability to fight off invading bacteria, simple infections that a healthy normal adult quickly recovers from can become the kiss of death for an elderly person with a weakened immune system. For these reasons, certain foods should be avoided, everything needs to be cooked properly and measures need to be taken to prevent cross-contamination.
6. Servicing the elderly population will also mean treating patients with a large variety of conditions that affect their food intake. Renal disease, heart disease, diabetes, cancer, malnutrition, over-nutrition, diarrhea, constipation and so-forth.
7. Dental problems affect food intake. A person with dentures, few death or mouth pain may not be able to eat solid foods.
8. There’s happy old people and miserable old people. Everyone knows that sometimes a cranky old man or woman has no respect for what you tell them and no tolerance to listen to you anyways. It’s important to have a FIRM hand while being understanding.
9. Medical treatments and medications have serious side-effects that could affect food-intake. Severe diarrhea, dehydration, loss of the sense to taste or smell, nausea… may cause a person to be afraid of eating or have a loss of appetite. A low intake of food in an elderly person is common, so it’s important to relieve the underlying caused or suggest ways to make food more palatable.
10. Communication - sometimes when we get old we can't think, talk or speak so well. Somehow as nutritionists we need to communicate effectively despite any barriers. 

That’s A LOT of things to think about when you’re trying to assess the nutritional status of a client. I’m not saying it’s impossible, but it’s certainly challenging and depends on each individual patient. You need to use your best judgment in every situation and also, don’t forget to be compassionate.

For the last part of my visit to LCDA, I was able to stay in the office with K. while she had a consultation with a patient. Every patient has a file they bring with them, so the medical records and current treatments are all visible to each health professional. In this way, the patient doesn’t have to repeat all of their medical history, etc. etc. during each consult. After reviewing the records, the nutritionist measures height, weight, BMI and completes a 24-hour recall (which we know is not very accurate, but it’s the best tool we have). Based on this information, the nutritionist will make very general recommendations: try to eat more vegetables, drink low-fat milk, drink more water, and suggest supplements (vitamins, Metamucil, etc.) that will be helpful in relieving diet-related conditions and generally improve the quality of life. Also, as much as you would like to avoid this topic, it’s important to ask about bowel movements. That’s right, “how many movements?” and “what does your poop look like?” NEED to be asked. As I mentioned above, diarrhea and constipation can have severe impacts on the food-intake and comfort of a patient. Relieving these conditions are necessary but not always easy to do.

Something I did not mention already, is “how do the people who visit LCDA” afford the services? La Casa del Abue is of no charge to persons over 60 years. The X-rays, treatments, doctor consults, dentist visits are all free. Generally the activities are free as well, or they may be very very affordable. The whole point is to take-care of our elderly population, while promoting their physical and mental well-being. In Mexico, they do not forget their grandparents. They are a vital part of the family system and need to be cared for in ways other than providing financial support. I haven’t  quite figured out well LCDA is being funded completely by the government, and since it’s fairly new, I’m not sure if it will be maintained over-time. For the members of the Poblano community, I hope La Casa del Abue will continue to be an affordable resource for maintaining all aspects of health later in life – and a model for similar programs in the future.

INTERNING TIPS

1. Don’t let yourself become overwhelmed when working with a difficult patient or population. You are a professional.

2. Let’s not forget that the elderly are a VERY difficult population to service, for all the above-mentioned reasons.

3. No matter who your patient is, find the balance between having a firm approach while being compassionate.

4. Remember to ask about poop – addressing basic issues of diarrhea and constipation can seriously improve quality of life.

5. Nutrition is NOT always a science. Never forget to use some common sense and your best judgment, it will benefit both you AND your patient.

For more information check out http://www.casadelabue.gob.mx/CAPortal/ or http://www.dif.pue.gob.mx/index.php

 

Ciao!

 

 

Hospital UPAEP - Revisting my sick-bed

This week my Mexican mentor Isa and I visited my favorite hospital in Puebla… that’s right, Christus Muguerza (Hospital UPAEP). UPAEP is the University where I’ve been taking Spanish classes (and also where I studied in January). I’ve had a general tour of CM, been a patient for 4 glorious days, and now… I’ve met with the nutrition department and kitchen staff for some in-depth nutrition research.

If you remember from my blog, CM is a private hospital, which means it’s quiet, clean, has great resources and capabilities and is never really crowded (usually 4 – 20 patients). For these reasons and because of the wonderful staff they have, CM is the first hospital I have actually ENJOYED being in. Personally, I find hospitals in general to be cold, clinical and not a wonderful place to spend your time. That’s why I’ve never really had aspirations to work in a hospital. My my my, how things are changing.

Needless to say, I had high expectations for the nutrition department. When I say department, I mean the nutritionist on staff and her intern because there isn’t anyone else. Truthfully, there isn’t a need for more than that. The hospital has no more than 20 patients at a time and usually far far less than that. When we visited there were only 3 patients who needed lunch. Our first stop was to the kitchen. I was very glad to learn that CM has a separate kitchen for patients and the cafeteria. This is comforting because in truth, to have a kitchen only for patients offers more control, eliminating any cross-contamination AND unlike Hospital Puebla, the women who prepare the meals are not outside chefs contracted by the hospital. I can also say that the cooks are among the most wonderful employees of the hospital. It’s like having you grandma cooking for you. Which makes me wonder why I distinctly remember the food NOT being appetizing. During our tour they had beans cooking, rice, soup, and some stew. Maybe it was because I was so nauseous? Or perhaps the ‘yo soy vegetariana’ caused some issues. That happens a lot.

Anyways, in the kitchen, like at H. Puebla, the nutritionist sends a list including the diagnosis, diet order and room number for each patient. The diet orders correspond to a color system, and each food tray represents the color for each prescribed diet. For example:

Red – bland

Yellow – normal

Blue – diabetic

Orange – low sodium

Purple – liquid

Green – renal

This color system eliminates the chance for errors in sending the wrong diet UNLESS it’s the doctor that prescribes the incorrect diet (like my renal dr. forgot to mention that I was vegetarian, so I was sent meat juice at some point). Also, there’s a dry-erase board with the room numbers where the nutritionist/cooks can write special indications, such as “dislikes vegetables.”

The kitchen staff is responsible for creating the daily menu, which surprisingly changes a lot. There was a lot of fresh vegetables in the kitchen, and almost everything is made from scratch. The menu for this week looked something like this:

Monday

Breakfast: Quesadillas de requeson con espinacas/ Coctel de frutas natural/ Frijoles del la olla

Lunch: Codito rojos con jamon y queso panela/ Tostadas de pollo/ Tarta de duranzon

Dinner: Tortilla Espanola/ Frijoles refritos/ Gelatina mosaico

 

Tuesday

Breakfast: Chilaquiles verdes/ Arroz con leche

Lunch: Sopa de fideo/ Chuletas de cerdo en crema de chipotle/ Pina en almibar

Dinner: 2 empanadas de carne/ Platanos con crema/ Chispas de chocolate

 

Wednesday

Breakfast: Pambazo de jamon, queso y frijoles refritos/ Papaya

Lunch: Espaqueti blanco/ Pechuga de pollo asada/ Raja poblanas con crema y elotitos/ Naranja en cuartos

Dinner: Hot dogs/ Yogurt

I didn’t translate any of the foods because although foods like “espinaca” directly translates to “spinach” in English, a dish such as “chilaquiles” has no English equivalent. Hot dogs and yogurt are pretty obvious and I’m wondering what the hell that’s about anyways… hot dogs with yogurt for dinner!? Unfortunately, we find that the doctor is responsible for prescribing a diet and the kitchen staff creates the menu – leaving little room for the nutritionist to influence what foods the patients consumer. Although, there is more collaboration at CM with the nutrition department, and a doctor will in theory refer a patient to the nutritionist when needed. 

Something that I discovered about nutritionists in Mexico, is that generally at a hospital there is only 1 or 2 nutritionists on staff, they really only see patients when a doctor makes a referral, and for the most part – they have no area of expertise. They are general nutritionists responsible for servicing patients of any type of condition. I’m sure it’s not the same everywhere, and Isa did say that it’s possible to receive credentials for a specific area (for example, for renal care or diabetes). Also, it is rare to find a nutritionist with their master’s, it’s not as necessary in Mexico – a bachelors degree is sufficient to work. As it is in the US now,  bachelors degree is hardly sufficient for any career, especially the health sciences.

**Personal side note, I’m debating whether I should apply for the master’s program or not at the moment. There’s a lot of reasons why I should and an equal amount for why I shouldn’t. The master’s programs in New York City are all highly competitive as well, so I need to have A LOT of experience to even have a prayer at being excepted. I can tell you though that I am so relieved I didn’t apply to being this fall. I need time to gain real working experience, and to discover which area of nutrition most interests me. I thought I had it figured out, but we never really do. It’s ridiculous that students graduate with their bachelors and go straight to the master’s program without ever having to actually work. You wind up graduating at the ripe old age of about 24 with absolutely no work experience but lots of education. Who would you prefer to be counseled by? Do NOT, I repeat, DO NOT apply to a master’s program for the following reasons:

1.    Do defer your student loan payments

2.    Because you don’t have any current job prospects and you generally don’t know what you want to do in the future

3.    Because if you “don’t stay in school and do it now, you won’t ever go back and complete a master’s”

I won’t lie – all of these crossed my mind as excellent reasons to apply to a master’s program. Although Tripp will kill me for dissuading you from immediately starting your master’s, I stand by my belief that some amount of work experience, living in the real world will make your master’s a completely different experience when you decide to apply – one that you may just appreciate a lot more because it won’t be only “memorizing information,” but actually understanding how the information is applied. Receiving a master’s degree is necessary for our generation to secure us jobs that will pay a decent amount, but in general, I don’t respect a professional strictly based on their credentials. The truth is, there are endless career options in the field of nutrition (working for hospitals, nursing homes, schools, in the government, for a private company, for yourself… the list goes on!) With different work experience you’ll eventually find the area that suits you best. And if you discover you dislike your area, you can always try something new.

The point of my rant is that INTERNING and WORKING (usually you won’t be paid as an intern unless you’re unbelievably lucky) gives you knowledge and skills that being in a classroom can’t give you. It’s practical, applied knowledge. Classes provide you with all the information you could possibly know about a food, disease, diet, procedure, etc. but doesn’t give you the confidence that a hands-on experience will. For example, we learn that you need to be “culturally sensitive” when counseling a client. Ok. Well, the concept of “culturally sensitive” is generally meaningless until you’ve worked with clients of different backgrounds, religions, family systems with certain lifestyles and eating habits or preferred foods. All of these factors affect the food choices of a person and/or family. Of course we can never really know it ALL, but until you’ve been exposed to working with clients of different cultures, you won’t experience being culturally sensitive. It’s the experience that give you the true understanding of the word that we were taught in a classroom. Experience is the key to having more confidence in yourself and providing the best quality service as a dietitian.

Now that I’m done with my rant… I’ll leave you with some nuggets of advice that I’ve come to learn along the way. 

INTERNING ADVICE

1. To elaborate on my previous advice – there is a HUGE difference between private and public hospitals. For the best experience, try interning at either a large private hospital or a public hospital.
2. Don’t freak out if you don’t know for sure what you want to do – as long as you appreciate the opportunities that come your way.
3. INTERN. Yes, my intern advice is the importance of interning. Gaining real-world work experience is more valuable than any other way of learning. Learn to apply the information that’s been crammed into your brain to actual situation.
4. Plan on doing a master’s program. It will be necessary if you ever want a decent paying job – BUT I advise you to start the program when you feel ready.
5. Have confidence. This is the single most important advice anyone can tell you but YOU have to fully believe it. Have confidence in what you know and the decisions that you make because no one else can decide for you. It’s your life kiddo. 

Intern in Mexico

Now that I’m finally feeling better and speaking more Spanish, I’m ready to start doing some nutrition work. The Nutrition Coordinator at the University has been extending herself to help me gain experience over the summer. She put me in touch with a nutrition professor, Isa, who is fabulous. She’s young, experienced and best of all… speaks decent English. What more could I ask for in a mentor?

My priority now, is to continue learning Spanish – but more specifically, begin to build nutrition vocabulary. It won’t be helpful for me to head back to the states and not being able to use Spanish in a future job. By the way, quick side note – R. found this amazing book for me. It’s a dictionary of foods and gastronomy words from Latin America. YES, such a thing exists! For example:

Jugo: liquido que se obtiene de los vegetales por presion. Tambien el que se desprende de ciertas carnes por efecto de calor. Tambien suco. c. suc, e. zuku, g. zume, f. jus, i. juice/gravy p. suco.

Maybe I’m a total dork but I think it’s amazing. Obviously the only problem is, the definitions are not in English, so unless you speak Spanish... this book may not be helpful for you. In case you are interested, this is the information

Vivancos, Gines. Diccionario de alimentacion gastronomia y enologia Espanola y latinoamericana. Grandes Mauales Everest. Spain.

If you happen to know that the equivalent exists in English, please please please contact me!

Back to my work with Isa – so as of right now, it’s still a little limiting on what we can do considering I only speak a little Spanish. Once a week she arranges a meeting with the nutrition department of  hospital or other nutrition-related establishment. Then I have the chance to get a tour, see the kitchens, ask questions and all that jazz. It’s similar to the course I took in Puebla during January… tours of hospitals but those of course were all in English. Now I have the opportunity to be on my own and practice Spanish – also the meetings are specifically nutrition oriented, whereas in January their were public health students and dentists, so the tours and questions were much more general.

Since we had a cancellation on our trip this week, the only experience I can tell you of was our visit to Hospital Puebla. By the way, there are A LOT of hospitals in the state and city of Puebla. I can tell you that I was generally impressed by all of them for different reasons. Hospital Puebla is fairly new, and the nutrition department consists of two women. (Well, the one the we met with seemed very young, probably not much older than me and she looked younger). The hospital is fairly large (about 7 or 8 floors), but at the time we visited they only had 10 patients receiving meals. On the weekends they tend to get a little busier and can have up to 25 patients that need meals. The meals are breakfast, lunch and dinner, served at the expected times. The nutritionist who was giving us the tour first took us into the kitchen, where the meals for the cafeteria as well as for the patients are prepared. Interestingly, the hospital contracts a private company to be responsible for the food – so the food is actually cooked by chefs. Trust me, this is very unusual and only possible because Hospital Puebla is a private hospital. And the food smelled awesome. So jealous.

As great as this is for the quality of the meals prepared for patients, it also causes issues in the nutrition department. The main problem being: the CHEFS are the ones who make the menus. Periodically, they send a list of meal options to the nutritionists who can decide what gets served to the patients, but that is leaving little room for cooperation. So the food may taste fabulous but the nutrition quality is at risk. I’m not doubting the ability of the chefs to cook nutritionally sound food, but they are not trained to know which types of foods are beneficial or harmful to a patient with a certain condition. I was impressed that one of the chefs had a personal interest in renal disease, and made the effort to educate her on the nutritional aspect of the disease. However, this was her personal interest and does not imply that the other chefs are as interested in the nutritional quality of food for patients.

The job of the nutritionist on staff is to send the kitchen a list of patients, with room numbers and the TYPE of diet they are issued to receive. From what I can tell, the diets are your standard – normal, bland, liquid or diabetic. The nutritionist was pretty vague as to what foods were included in each type of diet – and remember, a lot was lost in translation (although Isa did her best to fill me in afterwards). From what I can recall, a liquid diet consists of: jugo de gelatina, consume de pollo, te and avena. A diabetic diet was obviously low on carbs, no fruit and low fat. “Dieta blanda” is generally foods with little flavor – like chicken with no seasoning, potatoes, rice – nothing spicy, salty, sweet.  There were a few specialized diets mentioned which included: high fiber, nephropatic, low sodium and restricted (which I didn’t get around to asking what exactly “restricted” entailed). She didn’t describe which foods went into the special diets.

We also briefly discussed how there are different procedures for preparing food for cancer patients. Chemotherapy and radiation treatments are meant to kill cancer cells, but in the process they also kill healthy cells in the patient. This process of constant stress to the body, leaves the person immuno-compromised. In essentials, a person undergoing cancer treatment has a lower ability to fight off bacteria – which makes it much easier for them to get sick and die from an infection. What does this mean for nutritionists? It means that we are responsible for ensuring that the food served to cancer patients are safe for consumption. Extra safe. The nutritionist at Hospital Puebla oversees the preparation for food destined to a cancer patient. First the kitchen is sanitized and no other foods are prepared at the same time. Only the food for the cancer patient in a very clean kitchen. They are extra careful not to cross-contaminate, use food from safe vendors, and cook all foods to the correct (or higher than correct) temperatures to ensure that the patient will not get sick.

The other responsibility of the nutritionists is to visit patients who have been referred to them by a doctor. Unfortunately, this is not always the best scenario as many doctors do not respect nutritionists (as I mentioned in my last blog). The world of health sciences is slowly evolving, but it’s not always common to see doctors including nutritionists in their team. So, at Hospital Puebla, if a doctor sees that a patient could benefit from meeting with the nutritionist, he will write a referral. The nutritionists visit these patients, asses what the problem is, learn what kind of foods (if they can eat) they prefer and make periodic follow-up visits.

One thing that I certainly did NOT like about the hospital, was their patient room assignment. On the one floor we visited, there were some maternity patients, the neonatal room, and one man who had kidney and gastrointestinal issues. A little separation is needed, especially from the babies. Speaking of the preemies, I found it interesting that the nutritionists were not responsible for them in any way. Feeding was the responsibility of the nurses – and the neonatal room contained a special room for milk storage.

Our visit ended after the tour of the kitchen and one of the floors with patients. Considering they only had 10 overnight patients I’m assuming there weren’t any patients that were seriously nutritionally-compromised, otherwise the nutritionist might have taken us to meet with them.

Unfortunately, I can't give you a personal comment on what I really thought of Hospital Puebla from a nutritional standpoint. It didn’t seem busy enough to get an inside look at how well department works and I wasn’t able to tell what the nutritionist actually does (especially when there are no patients who have been referred by a doctor). I’m not doubting their abilities at all - there's just no way for me to form a justified opinion after such a brief meeting. The visit was beneficial in remembering the differences between public and private hospitals. I mean seriously – they had trained CHEFS cooking the food. That is hardly likely in a public hospital. It was spacious, clean, new, quiet and even had a restaurant area. Certainly a nice place to stay as a patient but I’m not sure how much “experience” I would gain as a regular intern.

INTERNING ADVICE: 

1. Ask lots of questions, even if it’s stuff you think you should know. Don’t be embarrassed to ask when you are unsure.
2. Not all hospitals were created equal – literally. There is a difference between PUBLIC and PRIVATE.
3. Visit as many hospitals, nutrition departments and nutrition settings as you can, and come prepared with questions!
4. Try to work with the kitchen staff in preparing meals of high nutritional quality.
5. Walk away with a better understanding of our field after every interning experience. 

Sick in the city - Intern becomes patient

In a lot of ways, this blog entry is the most enlightening, but different experience I have shared so far. It’s also very personal because in this situation, I am the patient, undergoing care at the Christus Muergoza Hospital (Hospital UPAEP) in Mexico.

I believe the infection began the Saturday night of my birthday and of course, no birthday is complete without a night of drinking. At some point in the night, I realized that I had to pee after every single beverage, which I contributed to “breaking the seal” theory. I didn’t think too much about it. Sunday was a fairly normal day, and then from Monday on I started to feel progressively worse. I had hot flashes, abdominal cramps, loss of appetite, but figured I was getting my period earlier (there was a little blood in my urine) and experiencing more intense effects because of the new birth control I started a few cycles back. I followed my usual course of action, popped a bunch of Advil, drank mass amounts of water, and shoved a few Tampax in my purse. Then I began to feel exhausted, the Advil weren’t solving the issues for very long AND.. I won’t lie… I was kind of an emotional mess. I cried a bunch because learning Spanish is frustratingly hard and I was so so so tired. Ignoring the suggestion of my boyfriend (who I will refer to as R.) to go to the hospital, I decided to wait it out until the monthly culprit arrived. Another sign to my stubborn brain, should have been on Tuesday night, after having a fit of tears and pillow-talk, well you know.. one thing led to another. I’m not saying it was BAD, but my body just didn’t seem as sensitive or right. Once again, I kept my thoughts to myself and figured it was because I was having such bad PMS cramps. I know. Stubborn.

Now we find ourselves at Wednesday. After barely getting any sleep Tuesday, I was so grateful to have classes, lunch and then time to go home. I felt pretty awful all day, not hungry at lunch and ate a peanut butter sandwich for dinner since the thought of cooking or eating anything else made me gag. Getting into bed, I pulled on a sheet, a blanket and a comforter. R. looked at me like I was nuts (we are in Mexico..) but I had goose bumps and the chills. R. fell asleep in 0.2 seconds like most men and I spent the next hour or so trying to stop my teeth from chattering. My body was convulsing – immediately reminding me of the time when I was a 10 years old, and woke up vomiting and convulsing in the middle of a summer night in New York – scared, but more exhausted, I finally passed out. Sometime later in the night or early morning I woke up burning hot. In a panic, I threw the blankets on the floor, waking up R. in the process. I don’t remember much after that until it was getting close to time to wake up for classes and there was no way my body was getting out of bed. I do remember pain, lots of pain, and then being cold again. I also remember telling R. I think I have a urinary tract infection, starting to put together some of the pieces that had occurred since the Saturday before. R. ran out to buy a thermometer, took my temp and turns out I was running a high fever of 100F or so. Being unable to make excuses for my condition any longer, I dragged myself out of bed, threw some clothes on and gagged at any breakfast options. By the time we got to the hospital Thursday morning (which I was thrilled to see, as I had taken a tour of Christus Muergoza back in January when I was a student with NYU), I was running closer to 102F and FREEZING.

I was admitted directly into the emergency room around 10am, and the doctor came to see me almost immediately. The first priority was addressing the fever while waiting for the results from my blood and urine tests. After explaining the pain to the ER doctor, he said that I either had appendicitis or a urinary tract infection (highly common in women). “Appendicitis” freaked me out a little bit, but I was sure that it was a UTI.  I was hooked up to an IV for the first time in my life and pretty much passed out while R. took care of my insurance information and admittance papers. I should also mention, that I hardly speak any Spanish so my translator boyfriend has been amazingly helpful throughout this entire experience. I have no idea how I would have kept it together if I couldn’t understand the treatments or diagnosis. At some point we were bored while waiting and decided to google the causes and symptoms of a UTI. If you’re wondering what a urinary tract infection is, it’s when an infection occurs in your bladder, urethra, ureters and in more complicated instances, can spread to your kidneys. Not surprisingly I had all of the symptoms. Something interesting, the bacteria that causes a UTI is found in your gastrointestinal tract (Ahhhh E. Coli), and is common in women because of the close proximity between the anus and vagina. So, lucky us, being sexually active can increase your risk for a UTI. Why does this not happen in men!?

Sure enough, the ER doctor comes back a few hours later to tell me that I have a urinary tract infection but he wants a Urologist to take a look at me since the infection was so bad in my kidneys. I was feeling much better now that the fever had broken and I slept for a bit, so I was mortified when the doctor also said I would have to stay overnight. The rest of Thursday included getting my first sonogram… on my KIDNEYS and X-Rays. Don’t forget I’m still on the IV, and they bundled me up like an enchilada every time I had to be moved somewhere in a wheelchair. Very attractive. R. had fun with the sonograms, he kept making baby jokes and taking endless fotos of the kidneys I was pregnant with.

The Urologist was kind of a jerk. He came in and punched my kidneys which OBVIOUSLY hurt, and put me on antibiotics. That’s when I no longer felt good. I managed to eat ½ of a smuggled peanut butter sandwich and some cranberry juice. Trust me, if you saw the hospital meals here (or anywhere) you would not eat them if you’re life depended on it. Unless you’re R, because he clearly enjoyed it. This made me feel better because the ladies who bring the meals are the sweetest people in the whole world, and it was like disappointing your grandma if you sent the tray back untouched. I was pretty exhausted the rest of the night and managed to sleep quite well despite the nurses coming in at all hours to change IV bags, meds, check my temperature, blood pressure and all that jazz.

Friday was stressful in a different way. I ate half of a mini donut for breakfast and then puked it up. Meals were not an option for the rest of the day, as the nausea got progressively worse. At least R. enjoyed the rest. Not to make too much fun of him, he hardly left my room so he was hungry enough to eat my hospital food. The Urologist came in for 2 seconds in the morning saying he needs me to pee in a cup right AFTER I had already gone. When you’re not drinking anything, that kind of news pisses you off.. it was like my one shot for the day was gone! Amazingly I managed to keep throwing up even on nausea meds. Finally, later in the day I managed to pee and the Urologist came in to tell us that my abdominal pain and nausea was caused my too much intestinal matter (poop) blocking my intestines. Most of this conversation was being translated to me, but I assure you.. the words “enema” did not sound appealing. Luckily R. was pissed off at this doctor who clearly didn’t pay very much attention to me as a person, or my file. After a few discussions with the hospital admin (who had given me the tour during January, was a fellow NYU student and happened to be a friend of R.), the Urologist decided to get his act together. He came in and although sticking to his “intestinal” theory (which is impossible considering I hadn’t eaten anything since Wednesday and had pooped the day before), he decided to refer a Gastro-Intestinal specialist to us. That was a relief since there is nothing more frustrating than a doctor that believes his thoughts or plans of action are the only reasonable ones.

            **SIDENOTE  - There are a lot of doctors out there who well.. think their word is golden. They don’t have much concern for the doctor-patient relationship, actual concerns or requests of the patient, or with the collaboration between other medical professionals. This will become clearly evident as a dietitian working in a clinical setting. Some doctors will not be willing to appreciate or acknowledge our area of  expertise. The truth is however, we know the full relationship between food intake, health and patient recovery.. as well as an understanding of the emotional and physical stresses to a patient that can’t eat, is malnourished, or at risk for becoming nutritionally compromised. Our     field will eventually gain more respect, as doctors and other health care professionals will come to understand that a patients’ NUTRITIONAL  STATUS can help or hurt their recovery process. If the underlying causes of a condition are nutrition-related, the condition can not be properly treated until all of the underlying ones are.**

Oh I should also mention that the Urologist suggested I take a mild laxative mixed with juice. Mind you, I hadn’t been able to keep anything down at this point, but I was trying to have faith that it might solve the “intestinal” theory and relieve some of the pain. The photos of me drinking brown orange juice are priceless. I look quite disgustingly sick at this point, and about 20 minutes later I puked my brains out. So much for that approach.

The Gastro-Intestinal doctor came by around 8pm. I lie down and make painful faces as he pokes and taps the areas of suspect. The tapping part is kind of funny, it goes from sounding hollow to a solid THUD below my rib cage on the right side… hello enlarged liver! So the “intestinal theory” is out and now liver complications are in. Possible causes include Hepatitis or a reaction to the medications. The only way to be sure is to wait for the morning and run more blood tests and take a sonogram of my  intestines. Not thrilled about having to stay another night, I couldn’t ignore that the pain was definitely not getting any better. Speaking of the pain, it’s hard to explain the type of pain that a kidney infection and swollen abdomen cause. In part, it’s similar to the worst cramps you’ve ever had in your life (if you’re a woman) combined with nausea, hunger, and more nausea. It’s almost like when you’re so hungry that you get nauseous but the thought of food makes you gag. The doctor also mentioned that kidney infections are some of the worst pain you can experience. Fortunately, women can tolerate more pain than men – hey the doctor said it, not me! According to him, he has a male patient with a similar infection and the man was screaming like a girl. My method of dealing with the pain was to somehow convince my body to sleep. It only works for a few hours at a time, but those hours are glorious.

I also would like to discuss the nursing staff or “enfermeras” at the hospital. They were all consistent in coming in to check on my temperature, blood pressure and heart rate. I know that there’s machines that monitor those sort of things today, but I’m sure they’re costly and probably not more accurate than doing it by hand. My only issue with it, is that the nurses would constantly come in ALL night long. There’s nothing worse than being gently woken up at 3am in order to have your blood pressure tested and to tell the nurse how many times you’ve peed. Try falling back asleep after a few times of that… it makes for a very restless night. Especially since sleep was my way of avoiding the pain! I can’t complain though, I would much rather experience too much attention from the nurses than too little, that’s for sure.

That brings us to Saturday. I woke up not feeling so great and nauseous. Once again, time for blood tests and sonograms. They wheeled me down to the lab, all bundled up like and enchilada again. This time they weren’t looking at my kidneys, since the infection was under control, but at my liver and spleen. Surprisingly my liver appeared normal, spleen was slightly enlarged but other than that everything was fine and the abdominal pain and bloating remained a bit of a mystery. Luckily, the blood results showed that my liver was functioning perfectly fine so the Hepatitis possibility was out. In the afternoon, the Urologist and Gastro-Intestinal doctors came to my room with R. standing in-between then asking a million questions and translating bits and pieces to me. Looking up at all three men from my hospital bed, still chained to the IV, I couldn’t help but feel like a guinea pig. They all looked confused and kept pushing my over-extended abdomen, like the answer was magically going to pop out. Trust me, the only thing that was going to pop out at this point was farts or water. By this point I was so sick from hunger I requested a bunch of Ensure. The doctor suggested I try a liquid diet anyways, so I might as well go for something with actual calories. With my nutritional background, I knew that there was no way I was going to feel any better if I didn’t start eating something. As soon as I finished the first Ensure, I felt 10 times better. The nausea was gone as well as some of the abdominal pain. I started sitting up, typing, showered and put real clothes on (I only wear spandex and cotton shirts anyways). For the first time I felt like I was back on the road to recovery. Two and a half Ensures later I was starting to regret my decision. Partly from the IV, and partly from the dense Ensure, my whole body slowly became swollen. I noticed my legs, ankles, breasts, and worst of all – stomach had become gigantic. At some point I was standing in front of the mirror naked, horrified that I looked 3 months pregnant. I assure you, any woman would be mortified. Once again, R. found this highly entertaining and we managed to joke about it for the rest of the day. If I thought that the abdominal pain was bad before, this was equally as painful. The pressure on my abdomen was pushing on my diaphragm – limiting how much I could breath in and out.  I felt like a 40 pound Thanksgiving turkey that’s about to explode. The Gastro doctor came back and when all I could say was “estoy llena!!” he smiled and told me I went a LITTLE crazy with the Ensure. Listen, you wouid too if it was the only thing you could ingest in 3 days! Being the natural fatass I am though, I started craving mashed potatoes and asked R. to call the kitchen. Let me tell you something, those were the best damn mashed potatoes I’ve ever had in my life. I was willing to risk exploding for them.

We also had visitors that night. A friend and his mother-in-law, which are practically family to R. came in and cheered up the slightly gloomy hospital atmosphere. Don’t get me wrong, R. and I had a lot of good laughs up to this point, especially about me looking pregnant or like I would float out the window if I wasn’t tied to the IV, but it was nice to see other people again. Speaking of family, have I mentioned mine? Oh boy. Well… I doubt that any parents with a daughter that’s hospitalized outside the country would feel all warm and tingly inside. Thank goodness for Skype, so I was able to chat with them. Since they could see me (mostly at the times when I was feeling better), they were slightly relieved. Plus the fact that R. refused to leave me helped to ease the situation. I also did my part by sending the funnier photos, like the my butt peeking through the back of my hospital gown and my cheesy  smile while eating the world’s best Mexican mashed potatoes. 

Before sleeping we decided to go for a walk and do some exercising. This is when I realized R. could have a future as a personal trainer. I doubt I mentioned it, but he’s a runner and very active. He’s actually training for the Chicago marathon (yeah, me… not so much. But I like to watch him run by while I walk.) I did a whole routine of leg stretches, bending, some yoga positions. I basically felt like I was doing prenatal yoga. Saturday night passed like all the rest. Hard to sleep, especially since I’ve only been able to sleep on my back and I’m one of those fetal position sleepers. After more interruptions from the enfermeras, and I suppose sometime around 3am I felt pretty awful.  My eyes felt like they wanted to pop out of my head and my nose was bleeding. I also still felt like a stuffed turkey. I washed my face, stopped the bleeding, and walked around in circles. I suppose I managed to fall back to sleep at some point.

Sunday I woke up pretty excited because TODAY IS THE DAY I get to go home! Still feeling a head cold, I took a shower and felt a little better. I was so thrilled I even ate my cereal and a donut for breakfast. I gagged a little when they took the IV out… I didn’t see it go in so I didn’t realize it was a 2 inch long plastic needle that was in my arm. Surprisingly, I hadn’t been weighed at all during my stay so when R. found a scale I eagerly jumped on. Big mistake. If I was pale before, you should have seen my face when I realized that I gained 6kg (which is MORE THAN 12 POUNDS) in my 4 days at the hospital. No wonder I looked like I should be rolled down the hallway. Traumatized and feeling exhausted, I managed to be all smiles when the doctor came in. My only question was “is this swelling going to go away, and if so, when?” Once again, if you are a woman, gaining 12 pounds in a matter of days WITHOUT eating is like hearing that your dog got hit by a car (alright maybe I’m exaggerating slightly, but I mean, seriously… even my SPANDEX were too tight). Yeah yeah, I know, the important thing is that I’m on the mend and I’ll make a full recovery. I just can’t help but be a bit depressed by the fact that it took me 10 minutes to reach my feet to put on sandals. R. is pretty thrilled that my boobs are huge (not that they were that big to begin with).

Thankfully the doctor approves my discharge from the hospital, writes me a prescription for more antibiotics and painkillers, and gave me a big hug. It’s moments like this that frustrate me for not being able to express myself in Spanish. I would have liked to thank him from the bottom of my heart instead of having it translated, but I’ll spend the next few days practicing my Espanol and writing thank you cards to some of the hospital staff. Thinking I was home free, I realized there was still that little matter of payment. I literally closed my eyes and held my breath as R. told me how much the bill came to. All I can say is THANK GOD I got sick in Mexico, because there is no way in hell that 4 days at the hospital would cost that little in the US. I would have owed thousands and thousands and thousands of dollars. I’ve always had health insurance, but I am no longer eligible now that I am not a full-time student anymore. The way it works in the US is, that you can receive insurance under your parents until you’re 25 as long as you’re a full-time student. Since I graduated in May, I am now officially screwed. To continue my same health insurance, it will cost me $400 - $500 USD PER MONTH. I don’t know about you, but I’m broke. Yeah, bye bye health insurance. I think health insurance alone is a reason for me to stay in Mexico.

After getting over my shock that I could actually afford my hospital stay, we had to go through the whole discharge process which was exhausting and took a few hours. Finally, we made it to the car and I were on our way home! Ok, I won’t lie, we stopped at Walmart (did I mention that Mexican’s L-O-V-E Walmart?) and I bought jelly, Kraft Mac-and-Cheese, my drugs at the pharmacy and tampons. Yeah, it’s not bad enough that I’m already terribly sick and bloated, but I got my period today too. Basically, I can barely move and the thought of even doing anything exhausts me. But being home, in my own bed, is the most amazing feeling in the world.

I’m still not back to my normal, healthy self, but given a few more days, the infection will finally be gone and the antibiotics will be out of my system. I can’t pretend like it was the worst thing that could have ever happened to me – I am thankful that it was only a few short days at the hospital and I will make a full recovery.  I’m looking forward to my beach weekend in Veracruz at the end of the week (hopefully I won’t be mistaken for a beached whale). Despite any of my complaining, I can not even begin to tell you how blessed I feel, to have undergone such an experience, with the man that I love. I learned more than I could imagine about myself, my profession and about my relationship. You know what they say, “whatever doesn’t kill you, makes you stronger.” Cliché, but it’s the honest truth. Sometimes as healthy, normal human beings, we forget that we are mortal, and that there are more important things in life than the annoying daily trials.

This experience has been the most enlightening compared to any interning opportunities. Although nutrition wasn’t a huge factor in my condition, it was still an issue. Most of all, it has taught me to have empathy for the patients we will be responsible for. Empathy involves understanding the emotional and physical condition of the human being that we are meant to help. Patients will be confused, upset, depressed, disappointed, scared, hungry, not hungry, uncomfortable, homesick and just plain sick. Especially if they are alone or in a foreign country, don’t speak the language, or a number of other reasons. No one enjoys being in pain and away from their home. It’s a frustrating job working with patients, especially if they can be difficult or demanding. That’s ok. Our job as nutritionists is to: improve the quality of life for the patient. Never, ever forget that. 

INTERN ADVI CE

1.    Have empathy for your patients

2.    Our job is to improve quality of life

3.    Our job can be frustrating: patients can be difficult and so can doctors or other health care professionals – deal with it! 

4.    Don’t treat a patient as a number, treat them as a person

5.    If underlying causes of a condition are nutrition related – not addressing the patients’ nutritional status can hurt their recovery

 

Much thanks and love to everyone – S.T.