By: Hannah Etman
In the days leading up to my clinical rotation, I wondered if I had done enough preparation. I had been told countless times that in my clinical rotation I would finally learn to apply the knowledge gained through past coursework and assignments, but I couldn’t help but feel uncertain of what the next 10 weeks at Meritus Medical Center would bring. Entering a 257-bed hospital with little hospital-based dietetics experience was a nerve-wracking experience, but a welcomed one. The excitement and anticipation that I felt upon beginning my clinical rotation were enough to push away the doubt that sometimes crept up—and this ultimately led to an incredible learning experience and a stronger leaning towards clinical dietetics as a career path.
Seeing patients on general medical-surgical floors contributed greatly to my growth as a clinical intern. I spent the bulk of my rotation on these floors, seeing varying degrees of mostly medically-stable patients and helping to determine their best course of nutrition-related care. Because most of the units at Meritus include a wide variety of patients and disease states, I was constantly shifting gears—seeing patients with renal issues, tube feeding requirements, and heart failure, to name a few. For the first six weeks of my rotation, I spent one to two weeks at a time with a different dietitian, learning the ins and outs of their assigned floors and patients. One of the most significant takeaways from these six weeks was the importance of viewing the patient’s clinical picture as a whole. Patients often had multiple comorbidities and therefore I had multiple things to consider when determining their specific nutrition therapies. It was crucial for me to critically evaluate all aspects of their chart before interviewing them so that I could ask them thoughtful, detailed questions. On some medical-surgical units, I attended multidisciplinary rounds, but on others it worked best for me to evaluate the patients’ charts and then speak to them directly. Ultimately, determining nutrition therapy for these patients came down to their whole clinical picture, other providers’ recommendations, and my discussions with patients.
After spending the first six weeks of my clinical rotation on medical-surgical units, I had the privilege of rotating in the Intensive Care Unit (ICU) for two weeks. This was the most highly anticipated experience of my clinical rotation and one that I had unknown expectations for. I quickly learned that the fast-paced nature of an ICU forces you to be ready to change gears at nearly any time. Patients are constantly being transferred in and out and diets may need to be upgraded or downgraded which requires a level of precision and attention that is often more intense than on a medical-surgical floor. This is not to say, however, that any type of unit is easier or more difficult than another. Each unit and patient is different and requires varying levels of care, some requiring little attention and some requiring many follow-ups and changes in care. In the ICU, I spent much of my time practicing tube feeding calculations. Many patients that I saw were either on ventilators or unable to eat food orally and usually required enteral feeding. This meant I spent many of my hours calculating a patient’s estimated nutrient needs, calculating a tube feeding regimen that met those needs and confirming my work with the ICU dietitian so that she could fill in the order on her computer. While in rounds in the ICU, I noticed myself listening intently to what each of the nurses, doctors, and other providers had to say in case anything affected the patient’s nutrition therapy. When there were terms or references that I did not understand, I made sure to write them down and either look them up later or ask the dietitian to explain them to me. Throughout my two weeks in the ICU, I learned to be okay with switching tasks quickly and prioritization. Many different problems or situations arise and it is necessary to evaluate the urgency of each and plan your schedule around that. The changing, highly acute ICU environment helped me further develop my critical thinking skills, manage time wisely, and refine my tube feeding knowledge.
Another aspect of my clinical rotation that contributed to my learning was completing a minor and major case study. I chose two patients to study, write about, and then present my findings to the Meritus dietitians. For my mini case study, I chose an adult patient with a suspected fatty acid oxidation defect which interested me due to the infrequence of this condition, especially among adults. I completed a nutritional assessment on the patient, collected information from their chart, and spoke with the patient directly. Afterward, I completed a write-up in which I highlighted my findings from their chart and delved into a further discussion of the condition. I presented this to the dietitians at Meritus towards the middle of my rotation and received great feedback, which I attribute largely to many of the skills I honed during my rotation and while drafting my case study. Patient communication, time management, and my efficiency in assessing patients were reinforced when gathering information for each case study. For my major case study, I chose a patient during staff relief who came into the hospital with persistent nausea and vomiting and was later found with an intestinal obstruction. Similar to the mini case study, I collected pertinent information and completed an assessment on the patient, but I had to collect much more data due to the more detailed nature of the major case study. I went through all of the notes from providers, lab values, medications given, and their medical history. Right now I am in the write-up phase of this case study and will soon present it to the Meritus dietitians, along with other guests. By doing these two case studies, I have learned the importance of thoroughness. There were many times where I realized I was missing a small piece of information, only to have to go back into a patient’s chart to retrieve it. Because of this, I have become more meticulous when gathering the necessary information. I have also learned better methods of taking information and turning it into a presentable format.
Throughout my clinical rotation, I kept an open mind with a positive outlook in order to gain as much knowledge and experience as possible. It was especially helpful being able to experience the difference between nutrition therapy on medical-surgical units and the ICU. I left Meritus feeling extremely confident in my clinical abilities compared to how I felt when I was just beginning. I attribute much of this to smaller learning opportunities I had throughout my rotation and I am excited to apply what I have learned in future situations.