This was my first hospital experience and I was a little nervous for a few reasons. The major reason is that as a STUDENT we learn a lot - formulas, calculations, diseases, treatments - but the human aspect is completely lost. We learn how to treat diseases, not people. It's also easy to depend to what we KNOW such as the facts, in place of our better judgment, intuition, or as Linda refers to it - our ability to think critically. Needless to say, I found myself stressing that I wouldn't remember my cheat sheet of formulas, or all the different medications and their nutrition interactions, or which enteral supplements to recommend - you get the picture. I was also nervous about being in the hospital setting, especially the NYU Cancer Center. Sure, we've seen pictures of what patients look like when undergoing treatment or recovering from cancer, but the truth is - unless you've had a close friend or family member with cancer in the family, you don't REALLY know what to expect. So these were my concerns and reservations before my first interning experience at a hospital. Fortunately, all of my fears were resolved after my day of shadowing Linda.
Overall, the day was rather slow and we only saw to a few patients.
Patient #1 - Female who was suffering from chronic diarrhea - the apparent cause was that her tube was inserted too far in, leading to dumping syndrome.
Patient #2 - The first patient was a male, with a trachea tube, who had lost a significant amount of weight since he was released from the hospital and was having chronic constipation. His general state was depressed, sluggish, confused. Although Linda had met with him several times before, he seemed to be overwhelmed with what to do. It was noted that his discharge instructions were 1.5 cans of Ensure PLUS or Osmolyte 3x's/day. The weight loss is due to the fact that 5 cans of anything is not enough calories to maintain his body weight. We recommended him to increase the amount of cans to 6 - 7/day, increase his fluid intake and to try 1/2c of prune juice with warm water to help with the constipation. Unfortunately, the sluggishness, confusion and partial constipation was probably related to hypercalcemia, which we determined was not because of the feed, simply from the treatment.
Assessing Patient #2 involved the following:
- Reviewing lab values (significance of hypercalcemia)
- Calculating Estimated Energy Needs (EE)
- Determining how many cans of formula would be needed to appropriately reach EE
- Calculating how much ADDITIONAL fluid needed daily (the % of water in formula does not meet all fluid needs)
Patient #3 - The third patient was an elderly woman undergoing chemo for meta colon IV. We reviewed her charts and found that she had lost a significant amount of weight with a very low BMI. Although BMI is NOT indicative of nutritional status, it did show us that her status was fair, while being at high risk. Linda reviewed her normal diet, making suggestions throughout in order to make foods more FLAVORFUL (pt. had altered taste RT treatment) as well as to incorporate higher caloric/higher protein foods. The higher protein needs was evident from her low Total Protein and low Albumin levels. We also learned that she the Ensure supplement was no longer palatable to her, so she stopped drinking it. As an alternative, we provided her with a few samples of less creamy supplements, with the advice to try taking one (about 250cals) one hour before bed, in order in increase her caloric intake. She was also avoiding sugar because her son had told her that sugar feeds cancer. This IS true to an extent, but as Linda explained - sugar is the main source of energy for cancer cells, but it is also the main source of energy for ALL body cells. So if you're starving your cancer cells, the rest of your body is being deprived of energy as well.
Assessing Pt #3 involved the following:
- Calculating BMI and energy needs
- Interpreting lab values
- Recording a normal food intake
- Learning to ask detailed questions in order to receive as much information from pt as possible
- Working with pt to discover ways to increase caloric intake, increase protein intake - with the goal to STABILIZE her weight, pushing for some weight gain
- Writing a SOAP note!
Although seeing the patients seemed very "involved," as an intern - we're not expected to have everything memorized. Our job is to learn how the things we've learned in textbooks apply to REAL patients with real problems that can hopefully be improved up with nutrition intervention. The biggest piece of advice that Linda gave me was to never forget "the whole picture." Food/nutrition is only one aspect of a person's health status - and we need to be aware of what else is happening with the patient. There is no standard way to treat each person because not all body's are the same. There's a lot of trial and error that comes with working in a clinical setting, and it's our jobs as dietitians to figure out what works BEST to improve the quality of life for each individual patient.
INTERN ADVICE
- Know the whole picture
- Treat the person, not the disease
- Have confidence - we remember more than we think we do!
- Always maintain your composure
- DON'T stress, this isn't an exam! - the point of interning is to learn on the job
