University of Maryland Dietetic Internship

Tackling Football Nutrition

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.

HYDRATED

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.

Developing Clinical Judgment

By Emily Glass, UMD Dietetic Intern

After almost every nutrition lesson my college professors would add a caveat, such as “this will change, so you will have to use your own clinical judgment.” The concept of using clinical judgment has always scared me a little. I find I often ask myself what is clinical judgment? And how do I develop this skill?

As I began my clinical rotation, I made it my goal to establish great clinical judgment skills. When faced with a patient with no appetite and poor intake, the question arose: do I still give them the restricted diet that is recommended for their medical condition or do I give them a liberalized diet, hoping they will eat more. Checking in with experienced dietitians, I noticed that the opinion on what to do in this situation varied from person to person due to their own clinical judgment.

Clinical judgment is not rigid, but rather ever changing. I am learning to compile subjective and evidence-based information, and then critically evaluate and reflect based on my experiences and beliefs to determine the best course of action. Clinical judgment is a broad skill that is truly unique to every individual as a result of the experiences they have had throughout their career. In addition to a variety of experiences, the ability to self-reflect is vital. By reflecting on actions and experiences, I strive to make better clinical decisions for patients.

You do not just develop clinical judgment skills in clinical practice. I began my journey in nutrition at Johnson & Wales University studying culinary arts. I took rigid culinary classes, learning about origins of food and authentic cooking methods. This strong foundation in food has had an impact on my specific clinical judgment. I believe to understand nutrition, you must first understand food. My background gives me the ability to better analyze a diet recall from my patient and give great, realistic ideas for improvements.

The University of Maryland internship is special in that it continues to give me the ability to try many new things and interact with a variety of different people. Through every experience I’ve had in this internship, I have found ways to improve and grow my clinical judgment skills. In my food service rotation I gained a better understanding on how a hospital kitchens operates, the quality of food patients expect and how to provide great service to the patient. I noticed when a patient received great service and had their specific meal order taken, they often ate more of their meal and felt more involved in their care. This has helped me understand a way to potentially increase intake and how best advocate for a patient’s diet. Through my community rotation I gained valuable insight in recognizing the skills and information people already possess, which helped me see the gaps where I could provide education. By reflecting on my lessons in the community, I found certain tones and ways to approach a topic that work well.

Finally, five weeks into my clinical rotation, I have learned no patient is the same. The method that worked during the last diabetes education, may certainly not work the next time. But, by having the ability to pull from my many different experiences and reflect on what has been successful, I grow and improve my clinical judgement for the next time.

Although the skills learned in food service, community, and technology rotations are not necessarily clinical, they play a vital role in developing clinical judgment skills. By having a better understanding of food, the people within the community and the technology that is available, I have more information to draw from when making important clinical decisions.

My Multiple “Ah-ha!” Moments While in the ICU

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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.

icu pic — Image: Saint Alexandria Health Services

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.

Tackling Food Insecurity within Anne Arundel County’s Aging Population

By Becky Handley, UMD Dietetic Intern

Have you ever wondered where your next meal will come from?

For many older adults, this is a question they ask themselves almost every day. Whether these individuals are limited by access to transportation that links to a local grocery store, health conditions that limit driving or heavy lifting, or finances with little expendable money to pay for food, many older adults require assistance in finding their next meals. Luckily, with the help of Anne Arundel County’s Department of Aging and Disabilities on the east side of Baltimore, MD, hundreds of older adults in this area know where they are going to get their next meal to receive the nutrition necessary to maintain a high quality of life.

For my first community rotation, I had the opportunity to shadow the Director of Nutrition Services at the Department of Aging and Disabilities and learn the ins-and-outs of two of its nutrition programs, Congregate Dining Services and Home Delivery Services. In an effort to reach older adults who require assistance, Anne Arundel County divides eligibility for their nutrition services into two categories. For older adults who are self-sufficient, Congregate Dining Services are available at one of the 7 local Senior Centers located across Anne Arundel County. Here, Seniors ages 60 years and older have access to at least one meal a day that is healthy and balanced in each of the five food groups. In addition to free meals, a variety of educational programs, recreational activities, health screenings, seminars, and classes are provided to promote social activity, food security, and wellness in the community. For those who require additional assistance and do not have access to their local Senior Center, Home Delivery Services are an option. Each day, over twenty Meals on Wheels volunteers set out into the community to deliver two balanced meals, one hot and one cold, per day to Seniors who qualify for the program. Together, these two programs provide options and resources to older adults and enable them to live independent and meaningful lives.

Working alongside those who run the Congregate Dining Services and Home Delivery Services, I saw firsthand how much these Seniors depend on and enjoy these programs. After providing a snack with accompanying nutrition education at one of the Congregate Centers, I personally experienced the community members’ eagerness to learn more, as well as their appreciation for the interaction and healthful snack. And while delivering meals across the area, I witnessed the deep friendships the Senior members had made with the Meals on Wheels volunteers and their gratefulness for receiving assistance in securing nutritious meals. Working with Nutrition Services at the Department of Aging and Disabilities showed me how important these programs are to the local Senior community members, and as a future RD, how important it is to advocate for programs that support the needs of the aging community.

Navigating Clinical Dietetics: An Intern’s Guide to Personal Growth

-By Alexandra Long

I’ve been told by former dietetic interns that your clinical rotation is the hardest. “Good luck!” they’d say. “You’ll get through it!” Why did everyone anticipate I’d need these good tidings? I did well in my medical nutrition therapy courses in school; I have a strong clinical interest and was looking forward most to the clinical rotation. I assumed a smooth transition from my studies to the application of medical nutrition therapy with real patients. What other skills would I need?

As I am currently in the 9th week of my clinical rotation at Holy Cross Hospital in Silver Spring, MD, I can say that my undergraduate studies provided the knowledge base I needed, but did not prepare me for the complexities of the diverse patient population and medical conditions. This rotation has helped me connect the details in the progress of patient care. For example, I have a better understanding of how a specific lab or medication relates to the patient’s disease state.

While acclimating to the clinical rotation, I’ve learned these four strategies to make the most of the time spent:

Push myself outside of my comfort zone.

Before my internship, I did not have any experience with patient interaction. Knocking on doors and speaking to patients was not something that came easily to me. By reminding myself that I’ll only be able to help someone when I build a rapport, I gained the motivation I needed to see more patients and provide better care.

Take every opportunity to learn.

I’m fortunate to be at a teaching hospital with a preceptor that values interdisciplinary care. She organized for me to observe wound rounds, PEG tube placement, esophagram, and barium swallow, and sit in a gestational diabetes class. Two of these experiences helped me in ways I hadn’t anticipated.

While following the wound care nurse, I witnessed the debridement of pressure ulcers and maintenance of ostomies. From observing the amount of tissue and muscle loss in some of the wounds, I understand the importance of nutrition in the healing process.
As dietitians work closely with speech language pathologists, seeing their work first-hand with an esophagram and barium swallow helped me better understand the need for modified-texture diets.

Remind myself I’ll grow with time.

I’ve had growing pains throughout my clinical rotation. There will always be room for improvement, and I’m constantly striving to reach my next goal. Without challenging myself, I’d fail to realize my full potential. After each week, I look back to where I started as a reminder of how far I’ve come.

Remember to take care of myself while taking care of others!

It’s easy for me to become engrossed in my work, but I don’t want to burn out. I try to take time every day to do something that I enjoy. I’ve found that walking helps to relax my mind and relieve stress.

By following these guidelines, I know that I will get through my clinical rotation. I have so much to learn from my preceptors. Constructive criticism may be difficult at times. However, I’ve learned to appreciate the feedback as I know my preceptors’ intentions are to challenge me to grow. The former dietetic interns were right – it has not been easy. I have learned a lot already, and I am proud of my growth.