By Kelsey Felter

My clinical rotation days always start the same way: I wake up, put on my royal blue scrubs, make my coffee, pack my lunch, fill up two 64-ounce water bottles, and head out the door for a long drive to Meritus Medical Center in Hagerstown, Maryland. The rest of the day is anything but routine. During this clinical rotation I have been able to see many different patients with a myriad of health issues. Going into this is experience, I was slightly nervous thinking that the patients are so sick, how can I possibly learn all the information and ways to treat them? What if I do not understand something in the patient’s chart? Fortunately, Meritus uses an interdisciplinary team approach. The team is essentially a web of health professionals who share their experience and expertise to ensure each patient receives great, holistic care. My team is composed of a hospitalist or intensivist, all nurses on the floor, a pharmacist, a social worker, a nurse care manager, and, of course, a dietitian! Not only is this network effective, but I have found it to be extremely educational, too. I have learned so much from the team. Before clinical, I overlooked the significance of the interdisciplinary team. I knew it existed and would be a helpful tool; however, I had no idea that it would be a constant sounding board for my ideas and questions, a resource for excellent education, and a guide to improve treating patients.

I am currently in my seventh week of my clinical rotation. So much has happened over these past seven weeks, yet I still perfectly remember sitting in on rounds for the very first time. My preceptor and I were a few minutes early. It was 9:53 am and all was quiet. When 10:00 am hit, the atmosphere in the room shifted. The doctor stated a room number and a name, and rounds began. It was like hot-potato! Information was shared and my pen struggled to keep up. The nurse shared current diagnosis, past medical history, lab results, current mental status, bowel movements, family and patient wishes, and anything else to bring the team up to date. The pharmacist chimed in when necessary to discontinue medications or upgrade dosages of medications. The dietitian confirmed the patient’s current diet, intake, and swallowing or other nutrition concerns. The nurse care manager and social worker filled the team in on where this patient planned to go after discharge and if there were other family concerns. The exchange of information was constant, fast, and effective. Within about five minutes, the entire team was aware of the patient’s status and a treatment and care plan was determined. As I sat in rounds for the first time, I struggled to keep up. What was the medication the pharmacist just recommended? I was still writing down the nurse’s update post-op. What are TEDs? SCDs? Why was the patient going to CIRS? What was CIRS? Reflecting on this now makes me realize how much I have learned. Now I quickly follow the team and understand the acronyms, but I have learned so much more than that.

The interdisciplinary team is a concept I was taught in school. I recognized its importance at the time, but I had no idea how much being a part of the team would teach me and improve my communication skills. It all makes sense to me now. Each health professional brings a specific skill set to the team, and it has been educational for me to experience how the team tackles intense cases that require coordinated, round-the-clock care. One experience in particular taught me about the tedious process of ordering and initiating TPN. While in rounds, the Physician’s Assistant (PA) mentioned that a patient’s discharge was pending the central line placement and TPN order, as TPN was deemed necessary at this point in his chemotherapy treatment. There were many stressed and apprehensive voices from the team, wondering how we were going to get this all accomplished by the end of the day so the patient could be discharged and receive his chemo the next day. My preceptor communicated with the team that she would perform and document a physical assessment as soon as possible to help with insurance coverage and move the process along. I shadowed her as she performed a nutrition physical assessment on the patient. She informed the patient that he was malnourished and that she would communicate with his PA and oncologist to make sure they do everything possible to get the TPN covered by insurance and ordered in time to allow him to be discharged. By the end of the day, the TPN had been ordered, which meant the patient could have his central line placed and be discharged in time for his chemo treatment. My preceptor and I were overjoyed by the accomplishment. I learned so much more from this situation than I could have from any textbook or reading. I got to see a physical assessment for the first time, which taught me what to look and feel for when assessing the patient’s skin, muscles, bones and appearance. I also learned how constantly speaking with the patient, letting him or her know what you are doing and why can help the patient stay as comfortable as possible. Most importantly, I had witnessed the extreme importance of communication and time efficiency as every minute counted for this patient. I learned all about TPN in school; however, I had not learned about the process and making the initiation as time efficient, and stress-free as possible. This success was possible because the team coordinated their efforts.

As I reflect on my experience as part of an interdisciplinary team, I think back to my interview for the University of Maryland Dietetic Internship. I remember being asked to describe what attributes I brought to a team that made the team effective and successful. Now, I understand the significance of this question. To be a successful dietitian, you have to be a successful team member. You must be able to actively listen, communicate, ask questions, delegate, bring positivity, and be able to look at situations from different perspectives. Being a good team member is an important skill in life, especially when your team affects the health of patients. Working with the interdisciplinary team has taught me that you can know the facts, the education material, and the evidenced-based nutrition knowledge; however, problem-solving, open-mindedness and communication are the three most important skills when working with patients. Throughout my time in clinical, I have found that these skills are used every day in patient rounds within the interdisciplinary team, and it is quite amazing to be a part of. Therefore, in my career as a dietitian, I will not hesitate to seek advice from other health professionals. I have greatly enjoyed my contributions to the interdisciplinary team as an intern and look forward to working as part of a team in my future career. 

By: Danielle Ferguson, UMD Dietetic Intern

A few weeks ago, I was presented with my dream supervised practice opportunity – working with the Coordinator of Football Nutrition at the University of Maryland through the last few weeks of the football season. My internship director knew that I had a strong interest in sports nutrition and was able to arrange extra supervised hours working with the Registered Dietitian of the football team. This meant after my regular work day, I would head over to the football team house to continue my practice hours. I often worked over 10 hour days, but it was worth every minute.

When I arrived at the football team house each day, I would check in with my preceptor about what tasks needed to be completed that day and get to work. Some of these tasks included restocking the fueling station where the snacks were stored for the players, packing up the cooler with post practice nutrition, and creating infographics for the table cards in their dining facility. I learned about different nutrition products given to the student athletes and how they were specifically planned for their needs that day. Some of the products we used included muscle milk for recovery, tart cherry juice to reduce inflammation, and pickles to help restore electrolytes.

My preceptor and I spent a lot of time discussing the things she does to help the athletes on the team receive the proper nutrition to maximize their training efforts. Her job includes a wide range of responsibilities, including counseling the players on weight needs, working with the coaching staff regarding athletes’ post-surgery and post-injury needs, creating nutrition-related injury prevention guidelines, working with the dining staff in the dining hall to provide appropriate and healthy meals, tracking and ordering inventory of nutrition snacks for the team, arranging meals during team trips, and much more. She showed me how she is up-to-date on NCAA rules regarding nutrition, supplements, and training.  She worked with me closely to help me understand the level of commitment it takes to be involved with a Big Ten Collegiate athletics program and I was reassured of my belief that the hard work is worth it.  

Working for a collegiate athletic department is something that I have had my eyes set on for a long time. When I was younger, I thought it would be through coaching, but as I’ve grown into a passionate soon-to-be Registered Dietitian, I now hope that my role will be on the nutrition side of the field. Before starting this internship, I didn’t know that it was possible to have a rotation in sports nutrition, especially at the University level. I couldn’t be more thrilled to have had this practice and I am grateful to my preceptor and the University of Maryland Football Team for allowing me to participate with their team. This has provided me an incredible experience and I am even more enthusiastic about sports nutrition than ever.

By Emily Kohler, UMD Dietetic Intern

Being a new dietetic intern in an Intensive Care Unit (ICU) is not easy. The ICU is an ever-changing and fast paced environment that keeps even seasoned healthcare professionals on their toes. From what I’ve seen, the needs of ICU patients can be vast and they can vary greatly from other hospital units. While my two-week internship rotation at the University of Maryland Baltimore Washington Medical Center’s critical care unit was challenging, I believe I have found a passion for stabilizing critically ill patients with nutrition interventions. Here are a few of the many things I learned about how the important work of an ICU dietitian supports the unique needs of the ICU patient, and how this work differs from the dietitian’s work on a general surgery or cardiac unit of a hospital.

For starters, interviewing patients to understand their nutritional lifestyle is often not possible in the ICU since many patients are sedated, ventilated, or present with altered mental status. While the patient’s nutrition history is the dietitian’s bread and butter in other units of the hospital, verbal interactions with an ICU patient are limited and I often found myself hoping the patient’s family would be present to provide at least a snippet of information. This is not something I had thought about before heading to the ICU and I began to understand that an ICU dietitian’s intervention is not typically focused on a patient that won’t eat, but is usually focused on a patient that can’t eat.

In the ICU I quickly understood my perspective had to shift when configuring nutritional interventions: my nutritional experience up to that point was usually with patients that were able to feed themselves; I had rarely worked with patients that were unaware of nutrients entering them via tubes through their noses, mouths, or veins. More specifically, the ICU dietitian is often planning interventions using nutrition support methods, acting in a timely manner to initiate feeding with heightened and careful attention towards preservation of gut function. Starting with nutrition screens and assessments, I had the task of looking for clues as to whether the patient’s gut would be able to handle food or, should I say, formula. After determining that, I worked with the dietitian to create an individualized formula given a patient’s condition, creating the perfect balance for the patient’s needs. If a patient was already using nutrition support methods, I had to monitor data in order to determine how well the patient was tolerating the formula and create new goals for that patient’s feeding.

Finally, I saw that the healthcare team appreciates the dietitian as one of the spokespersons for the gut. The team has endless issues to keep track of and the dietitian facilitates feeding decisions that are added directly to the melting pot of the plan of care, providing counsel about when feeding should be conservative, when it is time for the gut to be stimulated, and when a feeding method should be re-evaluated. This recipe could turn sour without the dietitian’s attention to detail, efficient communication, and record keeping.

Providing nutrition interventions for ICU patients can be looked at as a prescriptive treatment, mostly void of patient decision making and interaction, but instead relies on the dietitian advocating for the patient’s nutritional needs. I felt as though my decisions during this rotation played an active role in the recovery of many of my patients; for example, the nutritional interventions I suggested aided in someone’s mother’s stabilization or were part of the reason someone’s brother preserved his muscle mass after a lengthy stay in the ICU. While there is a lot of potential death in the ICU, there is a lot of life that occurs with the help of a dietitian’s best clinical judgment.