Wednesday-day 3

Yowza! I got to try my muscles at assessing two patients today! Pressure is on! There is so much going on in a chart and you have to see a big picture and be able to then narrow it down to the issues pertinent to nutrition. I am still learning my way about finding information both in the chart and on the computer. Do know how to do energy requirement, tube feed and TPN calculations as if it was your own name! It makes for that much less things to worry about.

The awe of today came from the foodservice department. OSH is a Center for Excellence of the Morrison company. This means that whenever Morrison hires a new person they send it to OSH to be trained. That good! If you need more, here's this: OSH foodservice has very low turnover, and some people have worked there over 10 years. This makes for a great teamwork- and I even heard them sing a pep song before service today.

Yet another interesting tidbit: to get patient satisfaction high, the catering associate who is at bedside taking patient's order for upcoming meal also prepares this patient's tray and serves it to ensure continuity of service. I assisted in tray assessment today and one of the patients told us he has never had a better service (and care) despite being at few other hospitals.

Morrison is a part of Compass group (http://compass-usa.com/Pages/Home.aspx). This is the second time I hear about this organization, from a different perspective (I did a project on Eurest in undergrad dietetics) and I only heard great things from both. If you need a satisfying carreer- look up Morrison Management Specialists (http://www.iammorrison.com/)

Tuesday- day 2

I found out knowing meds that can affect nutritional status (which meds don't, right?!) is very important. You have to add that to nutritional assessment. The kicker is that our lab coat pockets are too narrow for the food-drug interaction book to fit into :( keeps your hands busy while walking down the hallways to other floors, I suppose ;)

Another tricky thing is learning to read other people's scribbles. I am really hoping the electronic record will become a reality soon.

Always read progress notes (which are often scribbled)! There may be a DNR order and in this case we can't start a tube feed/TPN.

Always look at Intake and Output to catch any signs of edema- it will affect what you can do with a TPN order.

I found out it may be possible to taste formulas, but not to get my hopes up- apparently they are as awful as they get. No wonder patients dislike them. The hospital uses 7 types of formulas (now, it may change) Pulmocare is the most commonly used, for patients on a ventilator, the other ones are Oxepa (septic pt), Nepro (renal failure), Nutrihep (liver failure), Jevity (stable pt with low PO) which has fiber and apparently tastes eeky, and Osmolite which is like Juven but has no fiber. there is also a ProPass- protein supplement that must be taken with food and something else which I forgot the name of but it's accessible through pharmacy department.

I sat on a couple of ICU rounds where the nursing staff presented case studies of current patients to other RNs, RD, and therapists: occupational, speech, physical, social worker, pharmacist and a pulmonologist. These rounds are helpful at catching small things because patients are given a real teamwork rundown. Often new consults are picked up by RDs thanks to this approach. At the end the patient (or attending caretaker) will be presented with the finished chart to sign. It helps the patients see they are being cared for.

Also, remember the name Diprivan or Propofol. It's a sedative/anesthetic that uses 10% lipid as base. It counts the same way as a lipid piggyback (1.1 kcal/ml) and you shouldn't use it in patients with elevated triglycerides or cholesterol.

Monday- day 1

I shadowed one of the newer dietitians, who by the way looks like Natalia Kukulska's twin sister (if you don't know the name, look her up, she's a singer in Poland). I got the overview of what happens as the day unfolds: printouts come first thing in the morning with the pre-screened list of patients to be prioritized to be seen for the first time and for follow up. The list was super long already. I found out the RDs usually get a list as short as 5 and as long as 20 (there are four dietitians total in Ocean Springs Hospital). The patients are divided by floors/units so that one person frequents the ICUs (there are two- medical and surgical) another person has her wing and floor and so on. Although our list was long we were only able to see maybe a third of the patients. Why? The hospital doesn't have an electronic medical record yet, so all pertinent data is in the charts. If the chart is in use- we can't have it, which means we can't access the patient's history, current meds and progress notes. The other reason why we couldn't see patients were anything from the patient being busy with another consult, being moved from the unit to a floor or vice versa, or being gone completely (MIA- perhaps gone for a walk). There were a few instances where we would come back three times to see if we can see the patient. The good news is: the medical record is being ordered and tailored to special needs of the hospital.

TIL:

1. RDs do not do education about insulin- it's RNs job.

2. Patients with Coumadin are screened as a Performance Improvement project for this hospital. They are then educated to be consistent with their consumption of dark leafy greens to ensure the drug is well tailored to their daily needs.

3. If there are too many first time consults, the follow ups get booted to second priority.

4. The hospital just staffed the Congestive Heart Failure clinic with an RD- yay!

5. 1 cup of melon counts as 5 oz of liquid (important for people who have fluid restrictions, like CHF folks or dialysis).

6. The assessment and education charts have been developed to make it easier to write notes in ADIME format (you know, the NCP thing).

7. RDs don't get to order anything here, only recommend to MDs on what to do.

8. RDs don't use Harris-Benedict, only kcals/kg, Mifflin STJeor or Ireton for folks on ventilator. 9. The other personnel is very kind and helpful. With very very few exceptions.

10. Things get hectic and there is nothing you can do about it.

TIL: snack food in the south

Yesterday was another day off, so the family enjoyed a leisurely time by the poolside. Yes, tan is coming along just fine, a little itchy at the tan lines. Afterwards we had a scenic tour of the neighborhood. There are still many properties for sale with only foundations remaining after the Katrina hurricane (Which reminds me, hurricane alert at the hospital is CODE HURCON).

Afterwards we went to have sno-balls at a local stand. I picked tutti-frutti and tasted strawberry cheesecake. Delicious! Must try again. Other odd flavors I'll have to investigate are: tiger's blood, seabreeze, shrek, pickles (I'm not sure about this one), hurricane, hanna montana (really?!), or dora the explorer (realy????!).

In the afternoon we ate crab and crawfish. It's prepared in a spicy broth so don't touch your eyes afterwards!!! Apparently there is a trick to eating crawfish: grab the tail and push it "like an accordion" under the thorax part of the shell, then pull away and voila! it comes off easily! (Thanks to Orlando for the accordion tip!)

I hope we have more crawfish soon so that I get really proficient at my new skill ;)

Orientation Day

Today I got to meet the majority of dietitians at both hospitals. I didn't really get to sight see, but I'm sure there will be plenty of opportunities for that in the near future.

The paperwork took longer than I thought- about 4 hours or so. I am not done, I have to finish an online orientation course by Thursday of this week (in three days).

The ladies at Human Resources gave me a couple of booklet/pamphlets about safety, procedures and codes used in the hospital (code black means tornado, blue cardiac/respiratory arrest, yellow- a chemical spill and so on) I had to take tests on those. The same applies for the online modules (there are 14).

The two security officers that helped with my ID and fingerprinting were fun and chatty.

I had some slow down with the labs since they didn't know I've already done a TB test two months ago. I sat down at the phlebotomist and as she was taking some tubes I asked what she was doing. Good timing! I avoided getting needles poking for TB.

Later I got to meet the food and nutrition service managers of both hospitals for a casual dinner.

Great time. The summer is looking very promising.

Oh, I've never been called a darlin' or a honey by strangers this many times in one day before.

Today I Learned (TIL)

You may find this information useful if you haven't known it already: on really hot days keep your car windows cracked open to avoid glass cracking from expanding hot air.

I have a black dashboard and it feels like a hot skillet to the touch: consider finding a dashboard visor or a cheapo option: large piece of cardboard to stick against the windshield.

The great dietetic internship adventure begins!

We survived the 17 hour ride south! Barely! Since we bought a little chest cooler air conditioner we thought we could leave during the day (departed from northern Iowa at 6 AM). Third of the way through we discovered it was a horrible decision. Once in Missouri, the car temperature started climbing past 80's, reaching a high of 100F in Arkansas. We were unable to get the car below 90's until past 8PM. This entire mistake resulted in three very unhappy and dehydrated guinea pigs. Each lost about 3% of body weight just over the time of our ride. As of right now, I think it may be alright, since they regained half of the weight overnight thanks to water, cucumbers and lettuce we've been feeding them every few hours in hopes to rehydrate the poor things. I suppose the lesson learned is: if you have animals but no ac (or you were assured a "chest cooler ac" will do the job), do not travel during the day.

So now for something of use to a potential future Mississippi dietetic intern.

I doubt you need driving directions- you can get those from google maps, and they are reliable. Something you do not yet get from maps is where to stop to gas, to eat or to rest. So here are my observations: there are plenty of gas stations along the road, so if you need to refuel- not a problem. If, however, you need a breether at a rest area- not much for choice here. Traveling from Iowa, there is only a handful of rest stops: all on interstates. This is a problem in general because over a third of the way is on state roads which do not have any rest areas (unless you count gas stations). There were two open (out of three total) rest ares in Missouri, two in Arkansas and one open (of two) in Mississippi. Some of the better stops were in Mississippi- well shaded, woody areas. The worst were in Arkansas- newly established, so without good shade or trees. On a day like yesterday (pushing 90 degrees) it is hard to really justify stopping: much better to stop at a cool gas station and roam around the convenience store section. This also helps fix the food issue: plenty of fast food and slower restaurants (think: Perkins or BBQ joints). Personally, I just packed some snacks so that I didn't have to stop (restaurants and gas stations do not allow pets so I had no option).

A problem you may run into is the duration of the trip. In our case it was 17 hours. I was lucky to have a co-pilot (kudos to my husband Brendon!) and we switched seats every three hours. I am convinced I could never do this trip by myself, so if you have to, you will most likely have to consider stopping at a motel (but there are plenty of those along the way too).

Overall, the route from Iowa to Biloxi is very well marked, so even without a GPS (which is our case), it should be easy to follow. All roads were 65 mph speed limit or more, with exceptions when passing cities. This means that the 1000+ miles flies fast. When done on a weekend- no problems whatsoever.However, we have done this route on a weeknight before- not as good: St. Louis MO, Jackson MS. and Memphis TN can be very congested during rush hours so plan your route with that in mind if you must leave on a weekday.

My project for tomorrow: meet with the preceptor at 8 AM at the Singing River Hospital for all paperwork and a tour. Then I have a week off while the tests (drug) and background check clear.