– by Kira Bursaw
Holy Cross Health is a health system in Maryland with two locations: Silver Spring and Germantown. For the last three months, I have been in my clinical rotation at Holy Cross Germantown. It’s a very new hospital with about 80 beds and one dietitian. I loved the experience and can see myself as a clinical dietitian in the future because of the amazing people who I was fortunate enough to learn from there. However, the majority of the hospitals in this area aren’t so small, and I wanted to have some exposure to the life of a dietitian in a larger hospital. When it came time to pick a 2nd clinical rotation (like a clinical elective for 1-2 weeks at the end of the clinical rotation), I jumped at the chance to head over to Holy Cross Hospital in Silver Spring. Coming from a smaller hospital, I hadn’t been exposed to some of the healthcare specialists which can be found in larger hospitals. Holy Cross Germantown did a great job of teaching me the basics of being a clinical dietitian and Holy Cross Silver Spring extended that learning by getting me out of the office and on rounds with a variety of healthcare specialists.
A big topic that dietitians and dietetics students hear about often is pressure ulcers and wound healing. I’ve received many nutrition consults for “the presence of open or unhealing wounds.” This label is most often given to patients who have a pressure ulcer, which can be stage 1 to 4 in increasing severity or unstageable if there is over 50% dead tissue. Before my rotation in Silver Spring, there was much information I could share on the role of dietitians in wound care and what the wound nurses’ notes said, but the problem was that I hadn’t had first hand experience. So on my first day at Holy Cross Hospital I joined Rezia and Agya, the wound nurse and the nurse she was training, respectively, for four hours of wound rounds. We went all over the hospital and to every single floor- from observation in the basement, to the SICU on the first floor, ICU on the second floor, and five more floors above that in two different buildings. I was able to see stage 1, 2, 3, and 4 pressure ulcers, as well as unstageable and deep tissue injuries. I also got to see how these wounds are cared for and the different types of ointments and dressings that are placed on them. There was a special silver gauze that was placed on diabetic foot wounds for one patient. There was a collagen gel that we placed on a stage 4 pressure ulcer of another patient- and the tube costs over $300! The nurses I shadowed seemed to know everyone in the hospital, and it wasn’t just by name; they knew about families and vacations and so many details about each person that you could tell they truly connected with everyone. I was very impressed by the proficiency with which they conducted their job and their personable attitudes when interacting with patients, visitors, and staff members alike.
I learned so much about the neonatal intensive care unit (NICU) from Olivia, a NICU dietitian. Olivia shares her office with Letitia, the pediatric pharmacist, and the two of them graciously shared their time with me. Olivia started out by teaching me about the most pressing issues premature babies face. Two of the most critical issues are necrotizing enterocolitis (NEC) and patent ductus arteriosus (PDA). Necrotizing enterocolitis is a condition I was familiar with from the adult population, but I had no idea how serious it is in the newborn population. According to Olivia, NEC is the number one greatest threat to babies surviving an early arrival, and a lot of what they do in the NICU is to try to prevent or minimize NEC. Olivia and Letitia showed me a video that explained the PDA defect; it gave me a better understanding of why some babies with this defect are so tired during feedings that they are not able to eat enough to gain weight. Babies that have an open PDA 
typically receive fortified breast milk via a tube (enteral nutrition). It is important to maximize nutrition care for these babies to keep fluids to a minimum while still providing adequate calories and protein to help them grow. Next, Olivia explained the different types of milk that the babies in her unit receive. Breast milk is used as the base in most cases and from there different additives can be incorporated to increase the caloric and nutrient density. The NICU uses human breast milk with an added fortifier. Human breast milk has approximately 20 calories per ounce and the fortifier can add an additional 4, 6, 8, or 10 calories per ounce. The NICU also uses products that are 24, 26, 28, and 30 calories per ounce, which can all be mixed with breast milk to create higher caloric density formula. Olivia did a good job of explaining all of these calculations and numbers, and the picture of the chart is a great reference that hangs on her wall.
There are two types of rounds that happen in the NICU: the true interdisciplinary rounds with all professions that treat the babies, and then there are the nutrition rounds that happen every day with just Olivia and the neonatologists. I participated in the nutrition rounds with two different neonatologists. There are four different rooms, labeled A through D, where the babies live around a central hub. The lights are dim and the rooms are quiet, despite all the nurses, parents, and other adults in the area. One cool thing I noticed was that there was a NICU Cam over every bassinet and incubator. These cameras are for parents to be able to see their newborns whenever they want, which must be very reassuring to new parents who can’t take their babies home yet. The neonatologists reviewed the caloric content of each baby’s feeding with Olivia and shared their concerns for the baby’s progress. One baby had patent ductus arteriosus and the neonatologist explained that the condition is being closely monitored, with the baby
likely to fully recover on its own. I was able to follow the discussion thanks to Olivia’s teaching on PDA. Olivia explained her recommendations of various calorie densities, always relating it back to how many grams the baby had lost or gained over the last week. I was very impressed by just how critical every numerical value was. After we finished rounds, Olivia took me to the room where the milk and formula is stored, to show me all of the products she taught me about. I have never seen so many different types of formula in one place! There were also two large freezers with the mothers’ breast milk stored and labeled with the infants’ corresponding ID stickers, as well as the bottles of human milk fortifier.
My 2nd clinical rotation was incredibly fast-paced and I got a crash course in a lot of areas that I didn’t have much prior experience. In addition to my time with both the wound and NICU teams, I was also able to visit the surgical intensive care unit (SICU) with the dietitian that covers the area and sit in on their rounds, which were quick and to the point. I’m very happy with both the solid base I received during my main clinical rotation in Germantown, and the supplemental training I received at Silver Spring.Together the teams at the two Holy Cross Hospitals provided me with a well-rounded understanding of all that dietitians do in a clinical setting.