An Unexpected Turn During Staff Relief

By: Haley Flambaum

Staff relief is a challenging time for interns. It’s a chance for them to solidify their knowledge, work independently and reinforce much of what they learned during their main clinical rotation. During their clinical staff relief, most interns are assigned a floor in their hospital and they are responsible for those patients. The preceptor expects them to see between eight to ten patients per day and update their charts. 

That was not the case for my staff relief.

My first week of staff relief started as normal. I was assigned to Floor 7 of my hospital and I was expected to see and chart those patients each day. Floor 7 did not have any specific types of patients, so I was exposed to a wide variety of medical conditions. I woke up on Tuesday morning of my second week of staff relief with a text from my preceptor saying, “Morning… looks like the COVID bug got me finally. I tested positive this morning and so did our Clinical Nutrition Manager (CNM). So when you get in just screen everyone except those in the Intensive Care Unit. Take as many as you can.” My brain was spiraling at this point thinking about how I was going to be the only inpatient “dietitian” there.  Per protocol, one of my preceptors still had to review my notes and co-sign them. This task was given to our outpatient oncology dietitian. My preceptor and CNM texted me saying that they trusted my clinical judgment. 

At first, I wanted to freak out. I took a much-needed deep breath and thought, “This is an opportunity that not many people get.” I decided that I would take this experience and use it as a way to improve my clinical nutrition skills. If my CNM and preceptor had trust in me, then I had to have trust in myself. I knew that I had the knowledge, gained from my undergrad and the previous 7 weeks of the internship, to guide me to a successful experience. 

I started each day by checking our consult list and then moving to screen regular floors to find follow-ups. My goal was to see every consult and follow-up each day. I screened 13 patients on the first day of solo staff relief. Prior to that, my maximum number for seeing and charting patients was 10. I knew I had it in myself to be effective and manage my time in order to see every patient that needed to be seen. After screening, I would make a sticky note of the categories of patients I needed to see. 

The categories were: 

  • Total Parental Nutrition (TPN)/Enteral Nutrition (EN): TPN is a method of feeding that is given through a vein. EN, also known as tube feeding, is a way of giving nutrition directly into the gastrointestinal tract. 
  • Follow-ups: Depending on the severity of a patient, that individual will need to be seen for a follow-up. A follow-up occurs after the initial consultation with the patient. If a patient is in a more severe nutrition state, per St. Joe’s Medical Center protocol, a dietitian will see the patient three days after the initial consultation. If a patient is in a mild nutrition state, a dietitian could see the patient a week to ten days after the initial consultation. A follow-up is meant to summarize events that have happened since the last time the patient was seen and to update their nutrition interventions.
  • Diet Education: Most diet educations I completed were about following a heart-healthy diet or a consistent carbohydrate diet. For each diet education, I would print a handout for the patient, go over the material with them, and answer any questions the patient had.   
  • Malnutrition Screening: Another healthcare discipline will fill out a form based on a patient’s nutritional status. The form covers weight loss, inadequate oral intake, open wounds, and more. The disciplinarian will score these categories. If the patient scores a two or higher, the nutrition department is consulted to talk to the patient.  
  • Nothing by Mouth (NPO): A dietitian will go talk to a patient if they have been NPO x five days (three if it is on a Friday).
  • Other: Other disciplines will consult nutrition services to talk to a patient and assess their nutrition status. For example, a doctor could consult a dietitian to conduct a calorie count if the patient is not eating properly. 

The diet educations were sprinkled all throughout the day. It is important that the patient receives nutrition education before they are discharged to ensure proper recovery at home. I started with TPN/EN because I knew those would take me the longest. I gained confidence in my TPN/EN calculation skills throughout this clinical rotation, so I was excited to be exposed to more opportunities to provide recommendations. I would bring my formulary card when I saw each patient. The formulary card contained all the information regarding my hospital’s enteral nutrition supplements and oral nutrition supplements. I knew this would be a valuable tool if a patient ever had a question about supplements. The formulary card also helped me decide which enteral nutrition formulas would work best for my patients that needed them. 

On average, I would see 10 patients per day. I wouldn’t have had the confidence to handle the situation on my own if I didn’t learn so much during my clinical rotation and gain the trust of my preceptors throughout the rotation. With the help of what I learned in my undergrad and what I have been learning through this internship at UMD, I was able to use that knowledge to help me succeed. By the end of the first week, I was seeing patients on my own and advancing my charting skills. With each completed note, came more confidence in myself and more trust from my preceptors. I was incrementally building my clinical judgment.  This experience taught me so much, especially how to have trust in myself and my nutrition skills. I learned what it would be like to be a clinical dietitian. I learned how to adapt to different situations depending on the patient. I also learned that it is okay to not know everything. This experience taught me the benefits of being flexible and adaptable in the world of dietetics … you never know what is coming your way.

Swallow and Follow

By: Rachel Amsellem

Swallowing, of course, is essential for patients to get the energy, fluids, and nutrients they need. During my rotation at Meritus Medical Center, I learned how speech language pathologists (SLPs) and dietitians work together to assess and manage swallowing problems in patients.  I was extremely interested in seeing a modified barium swallow (MBS) during my clinical rotation at Meritus Medical Center. Over the summer, I had to get a CT scan with contrast. I had no idea what to expect. I was told to drink a barium solution the night before and morning of the CT scan. I now understand that the barium was used as a type of x-ray dye. In a barium swallow procedure, the healthcare team can see the movement of the digestive tract. Radiologists and speech language pathologists (SLPs) are able to visually pinpoint where a patient is having trouble swallowing. They take a series of videos and images using X-rays of the mouth and throat as a patient swallows food and liquid of different consistencies.

I followed the SLP, Angela, to the first floor of the hospital where the patient was already in the X-ray room awaiting the study. We put on lead aprons and prepared different consistencies of drinks and food for the study. In dixie cups, Angela prepared honey-thick, nectar thick, and thin liquid drinks using the barium to mimic liquids with those consistencies.  In addition, she mixed a cookie with a barium pudding to represent soft and bite sized foods and graham cracker with a barium pudding to represent regular foods.

The MBS took around 10 minutes. Angela went one by one and announced which consistency she was giving the patient as I watched the X-ray on the screen and monitored the patient swallowing in real time. After the study, Angela labeled each video segment based on the consistency and if she saw any fluid enter the trachea. Angela was pleased because the evidence in the MBS matched the bedside swallow study she performed previously.

In addition, I was able to see some therapies that SLPs use to help patients with dysphagia, the official term for a swallowing impairment or disorder. Angela encouraged the patient’s swallow capability by implementing a chin tuck method. Reminding the patient about this therapy allowed maximal airway protection.

During this rotation, I also learned about the important role dietitians play for patients with dysphagia. Dietitians plan their menus, ensuring appropriate food textures and fluid consistencies are available while they are in institutional settings. They also counsel clients with dysphasia. In addition to the right consistency, many with dysphagia need guidance on good food choices that will help them get the nutrients and hydration they need. Meritus classifies liquid consistencies into four categories: thin, nectar, honey, and pudding. More facilities are moving towards the International Dysphagia Diet Standardization Initiative (IDDSI). The IDDSI is a framework which describes different food textures and drink thicknesses.  Check out this handout I made below which includes different fluid consistencies and its equivalent in the IDDSI.

In looking at my experiences related to swallowing issues, I think it is beneficial for SLPs and dietitians to know what swallowing techniques and other recommendations they each are providing a patient.  By doing so, they reinforce good swallowing habits and make it easier and safer for patients to swallow. Overall, dietitians and speech language pathologists can provide coordinated, client-centered care when working together.

Strawberry Field (Salads) Forever…

By: Lily Sheridan

Like the song was for the Beatles, my strawberry field (salads) served at St. Agnes Hospital were a big success. I gained valuable experience planning and executing a special hospital cafeteria meal, and the staff and visitors to St. Agnes Hospital’s cafeteria enjoyed a delicious meal. As a dietetic intern at St. Agnes, I had the opportunity to make a meal and serve it to the staff and visitors of the hospital. As part of my food service rotation, my partner and I decided to make a strawberry field salad with salmon since it was previously offered and very successful. We served the meal mid-September. We thought a salad with strawberries was a perfect way to end the summer season. 

We met with the retail food manager and estimated approximately 60 customers would come to our station during the lunch hours. The idea of producing 60 portions of a salad with salmon was very intimidating at first! Breaking the assignment into steps and collaborating with kitchen members made the production much more manageable. I learned that there is a lot that happens behind the scenes of service. For the first step, the executive chef shared with us the recipe database so we could find the recipe. We modified the original salad recipe because we wanted to incorporate salmon instead of chicken. Next, we ordered the ingredients to accommodate the number of people we were anticipating serving. The produce was delivered on a separate day from all other goods, so we had to be strategic in delivery dates to ensure the products would arrive on time. We ordered enough to serve 60 portions and have spare in case more was needed. Additionally, we had the delivery date two days prior to service, so there would be time to order more ingredients if there was a problem with the delivery.

The majority of food preparations took place the day prior to service. This included washing and cutting the strawberries and onion, portioning the mushrooms, pecans, bleu cheese and feta cheese, as well washing and portioning the spring mix. We also made a raspberry balsamic vinaigrette from scratch to serve with the salad. The salmon and bacon were prepared the day we served our meal. We spent a few hours in the morning getting all the salad ingredients finalized and set on display for service. The station would be open for the lunch hours of the hospital. My partner and I successfully served around 60 portions of this salad. 

Action Station Setup

Creating this dish to share with the staff and visitors of St. Agnes Hospital was a rewarding and educational experience. There was a lot of planning and labor that occured behind the scenes. Additionally, the quantity we needed to have available was a new challenge in the kitchen I had not faced. Seeing the satisfaction of the customers after they ate the dish made it all worth it! We had a survey available and received feedback from customers that they enjoyed this dish and wanted to see it again. However, since this salad was priced a bit higher than other meals in the cafeteria, it was important there was a special appeal to it. The salad was priced higher to cover the food cost to make it with some additional profit for the food service company. According to the recipe database, the recipe cost about $6.00 to make, this is largely because it is served with salmon. The food retail manager taught us to use that price to determine the selling point for the salad at $9.99, so there was some profit but it was still affordable. He mentioned that this recipe was unique because it is rarely served, so customers may want to take advantage of the opportunity. To keep that interest, the manager explained that the strawberry field salads should not routinely be on the menu, but rather offered as a special every once in a while. This experience has taught me about the amount of work that goes on behind the scenes of food service production. 

Finished Bowl

Into the World of Nutrition Counseling

By: Cameron Carter

What could be more ideal than counseling children and teens with their parents at Children’s National Hospital? Fortunately, I had that opportunity while working with a dietitian at their IDEAL clinic in Prince Georges and Howard County. The IDEAL clinic is an outpatient clinic that focuses on pediatric bariatric surgery and weight management. I was able to shadow a dietitian and get first-hand experience on nutrition counseling. Before this rotation, I was not aware that a teenager (16 years and older) could qualify for bariatric surgery. This rotation was very interesting, and I had a positive experience. 

In relation to nutrition counseling, I was given the opportunity to counsel every patient that was seen in the IDEAL clinic during my rotation. I used counseling techniques like reflecting, asking open-ended questions, creating rapport, and providing nutrition education. I also practiced using motivational interviewing, another major technique used in the pediatric setting. One child I met with was not seeing much change to their body and was not fully committed to applying the information learned in previous sessions. Using motivational interviewing, I got the child to commit to a goal that they thought they could achieve. I also was able to work with the nurse practitioner or doctor that would see the patients after the nutrition counseling and debrief them on my session. I would give a synopsis of the counseling session to the nurse practitioner or doctor, telling them the struggles each patient was having as well as the goals they set for the next month. Having a coordinated healthcare team allowed each clinic to function smoothly and tend to the needs of a large number of patients.

One topic in pediatrics that most parents deal with is selective eating. Parents told me they struggled with trying to get their child to incorporate different types of vegetables in their diet or that their child eats the same foods and will not try new foods. I created this infographic to give parents a way to get their selective eater to implement new nutritious foods in their diet.  

The biggest thing I learned was how important creating rapport is and how to gain the trust of pediatric patients. Since I was a new face, most of the patients I met with were a little shy or hesitant but as I created rapport and was able to find one or two things we both had in common. I was able to create a safe environment where the children felt comfortable. I learned that most children enjoy talking about the things they like to do, so I was able to get the kids guard down which allowed me to begin nutrition counseling. For example, I had a patient who typically did not enjoy coming for nutrition counseling open up and tell me about a hobby that even the current dietitian, who has seen the patient multiple times, knew nothing about. I was excited to hear the patient passionate about something and was able to get them to establish a goal by the end of the visit. 

Overall, I learned with nutrition counseling many patients have different struggles with eating a nutritious diet. It is important to individualize the counseling experience and find out the foods they enjoy so I can help create a positive relationship with nutritious foods. I also learned how important it is to get the parents involved. I saw that most kids who had a supportive parent or relative had a decline in BMI after multiple visits with a dietitian. I felt very comfortable counseling in pediatrics and truly enjoyed the experience.

Food Choices Survey and Cool Food Pledge

By: Elizabeth O’Donnell

During my week with Sustainability at the University of Maryland, I was able to gain insight on a great program that is being implemented in dining facilities across the entire campus. This program is known as The Cool Food Pledge. University of Maryland was the first university to adopt this program. The Cool Food Pledge started in 2015 with a goal to reduce 25 percent of emissions from greenhouse gases globally by 2030. Besides the University of Maryland, other institutions that have adopted The Cool Food Pledge include Panera Bread, Ikea, Hackensack Meridian Health, and PepsiCo. To qualify as a cool food meal, an individual’s breakfast should not exceed 20 percent of the recommended daily carbon footprint. A lunch or dinner should not exceed 30 percent. Many meals that meet  The Cool Food Pledge parameters are plant based. This is due to the fact that the meat processing industry contributes significantly to producing greenhouse gas emissions and raising carbon footprint numbers. Food waste is a leading factor contributing to the release of greenhouse gas emissions that are linked with climate change.

 One evening during dinner service at South Campus Dining Hall, I was able to help table a survey about food choices to any individual with a meal plan. There was an incentive to receive a prize of candy, a reusable produce bag, or reusable silverware upon completion. The survey written by graduate students and staff from Dining Services, started off asking about basic information, such as which dining hall the individual was attending, if they were a student, faculty, or staff, their age, gender, where they were living, the meals they typically eat in the dining halls, and the type of dining plan they had. The next question was very intriguing to me as it touched on the influences to their food choices in the dining hall. Personally, I will choose food based on my hunger level and what I am in the mood for. If I previously tried a food from the dining hall that I enjoyed, I would sometimes choose that food again. However, I do enjoy branching out and trying new foods, too. Many students dine with their friends in the dining halls. The following question regarding the importance of sharing asked if an individual’s food choices would be influenced by how easy it is to share the food. This is probably a question that I would not have thought of. Other questions in the survey touched on how important or not important it was to have meals that were seasonal, local, organic, environmentally friendly and sustainable, and minimized food waste. Overall, I believe this was the most fun and interactive way we could have involved individuals on the dining plan at the University of Maryland to provide helpful feedback. The participants also learned more about the basics of The Cool Food Pledge which is a significant part of the food and meals produced for this campus. Responses to the survey showed that many students did not previously know much about The Cool Food Pledge. So, by interacting with the students, I not only helped get information for Dining Services, but I also shared information with the students. Hopefully my time with the students sparked an interest in The Cool Food Pledge for them and ways they can make food choices that are sustainable for the environment. 

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