My RD Journey

From Undergrad -> Internship -> RD -> Private Practice!


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My First (Horrible) Experience with a CPE Seminar

As part of keeping your Dietitian title/license, you need to complete continuing education credits (75 over 5 years). It’s pretty standard for many other medical/health professionals as well (Pharmacists, RNs, OTs, PTs, etc). I have been leaning towards a mix of webinars, self-study courses, and lectures to gain credits. It works the best for me with having 2 jobs and an overall busy schedule.

Recently, I went to a seminar called, “Food Addiction, Obesity, and Diabetes,” provided by INR. I was super excited! It was going to cover overeating, binge eating disorders, managing food addiction, managing Diabetes, sleep, stress, and so much more. It would also be my first seminar and it was $81 for 6 credits, which isn’t too bad at all! Anyways, I made the 45 minute drive and attended with another Dietitian friend of mine. Let me just say, thank goodness for the free coffee and company or I would not have made it through the lecture. What a disappointment!

First of all, the lecturer (we will call her Dr. X) started late. Big pet peeve of mine! So, Dr. X does the introductions and starts off with the food addiction. She used a ton of medical terminology and definitely seemed liked she was very knowledgable. May I just say that “seemed” is the key word here. We get into food addiction, all very interesting; however, we are not following along in the 41 page (front and back) booklet I have, which apparently was due to someone different writing the slides. Anyways, Dr. X quotes a ton of research articles, which is great, except it takes an extra couple minutes for her to locate each one. This might sound great to you because she is using evidenced based research; however, for each claim she had 1 article and only read a few lines in the summary (not mentioning those involved in the study and other information you would want to know). Still not a big deal until we get to the first break and we are already very behind, aka we were supposed to had moved on to obesity and were still on the first section of the first topic!

As we get back from the first break, me with more coffee, I start to notice that when anyone asks a question, she gives a politician answer. By that I mean, she does not actually answer the question. Dr. X gave this round about answer quoting another 1-2 studies (spending the time to again find them) and leaving many people frustrated. We again continue to trudge along and make it to the lunch break. At this point, I notice that we are still not through part 1 (supposed to be on part 2 of 4) and that we spent so much time on the super science part (aka names of specific hormones and transporters) that I didn’t feel like I learned anything useful/practical yet.

So, my RD friend and I head to the in-hotel dining area, where lunch is not provided (my mistake for thinking my $81 also extended to lunch). Here we have another depressing scene: $7.95 for cold salad bar and soup or $12-something for the hot bar. Now, I am starving and want to check out the menu for the hot bar. We have vegetables (nothing fancy), bratwurst and cabbage (oh yum), chicken schnitzel, and potatoes with bacon. Glad I looked because chicken schnitzel means breaded chicken patties that you would expect to find in a school lunch program.  I went with the soup and salad bar, which actually had a lot of options, and a lovely dessert of fresh fruit and a cookie (very good). It seems lunch was looking like the highlight; however, I go in open-minded to our second half of the day.

In talking about diets, Dr. X mentions the diet fads; one of which is the Paleo diet. Her take on this is that we shouldn’t tell people to cut out food groups because it does not work long-term. I generally don’t tell people to start cutting things out in counseling either. Dr. X goes on to say that Paleo dieters cut out grains/carbohydrates, using those terms interchangeably. I have a few issues with this. One of which is that not all carbohydrates are grains (aka fruits). Also, many Paleo diet followers (many RDs I follow online) are more-so cutting back on the breads and pastas and aiming for majority of carbohydrates from fruits and veggies. Nothing wrong with that!

Right after saying not to cut foods out, Dr. X answers a question regarding red meat. Here Dr. X states to not eat the red meat because of it having saturated fat. My issue is meat quality. Grass-fed beef is way better than conventional fed meat (fed grains).  To quote Mayo Clinic: Grass-fed beef has,” less total fat, more heart healthy omega-3 fatty acids, more conjugated linoleic acid (thought to reduce heart disease and cancer risks), and more antioxidant vitamins, such as vitamin E.”

My last remaining hope died with Dr. X’s statement towards Diabetic meal plans. She quotes this (apparently from the American Diabetes Association) in terms of macronutrient distribution, “50-60% carbohydrates, 30% protein, and 10% fat.” What?! The AMDR for fat is 20-35% so 10% is way too low. What Dr. X might have meant to say was the American Diabetes Association recommends less than 10% from saturated fats. What frustrated me the most is that people in the lecture were taking notes and writing down things she said. This misinformation turns into what health professionals are then spreading!

Quick note: I am 6 cups of coffee in for the day (one of the best parts of the lecture was the unlimited coffee). We are getting to the last hour of the seminar and we have 3 parts still to go over! Dr. X decides it is a good idea to have no more questions from the group and to blow through about 25 pages (front and back) of information in an hour. Well, that didn’t turn out well. The seminar contained a lot of good information; however, I have to read through and learn it on my own. Part of attending a seminar is so you don’t have to spend extra time teaching yourself!

Besides my unlimited coffee for the day, one other benefit was that they had discounted self-study courses. I was able to buy 2 at $10 each (3 credits each) and one at $25 (5 credits). Great deals on interesting CPEs that I can use. Just as a disclaimer, I spoke to another Dietitian who attended the same seminar in another location and she had a much better experience than I did. I apparently just got the bad apple of the lecturers. Looks like I will be sticking to my self-study courses and webinars from now on 🙂

To end on a positive note, I went to my Dietitian meeting today and got a King Trumpet mushroom!

 

My Top Webinars/Self-Study Courses
http://www.todaysdietitian.com
http://www.dietitiancentral.com/ceu/continuing_ed.cfm
http://www.pbhfoundation.org
http://www.nutrition411.com

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Final Days of Staff Relief

Tomorrow marks my final day of staff relief and my final day of my IPC rotation! I will be starting on Monday at my long term care facility.

My past 2 weeks of staff relief have been crazy, but really good. I started off feeling a bit overwhelmed; however, as time progressed, I became very comfortable out on my own. Although this rotation was stressful at times, I wouldn’t have changed a thing. The situations I was put in tested both my knowledge and my patience. Some days went very smoothly; however, other days I was ready to leave at 10am. It was the days that I was ready to leave at 10am that I now appreciate the most. Being able to accomplish what needs to get done on stressful days has made me a stronger dietetic intern than when I first started back in August.

One of the things I will miss the most being at my IPC facility, besides the free breakfast and lunch I got each day, is having another intern with me. I had interns that came during my last couple rotations; however, they would come after I was already there. Sure, we bonded, but I was never with them long enough to really get to know them. This rotation was the opposite. I started my first day with another intern so we got through that first scary day together. I could not have asked for a better person to spend my rotation with. Besides the fact that she had awesome notes and charts I could copy (and cookies to feed me), she was sweet and always there to listen and vent to (as I was able to do for her some days, haha). We shared stories about our internships, patients, boyfriends, and frustrating situations. I used to think it would be crazy to share my internship rotation with another intern; however, I think having that experience (and becoming so close) made it all the better. Now ends the sappy part of my blog 🙂

Although there were people and things I will miss now moving on to my next rotation, there are certainly things I could live without. This refers to my 1.5 hour drive each way to my rotation, the long drive being mixed with snow, the obnoxious amount of potholes on the roads I take, and the 2 sets of train tracks I seem to hit every other day on my drive home.

Some of my favorite, interesting, funny, not-so-funny patients of the week consisted of:
1. A patient who overdosed on 270 pills.
2. A patient with a BMI of 54.4 (also unemployed and adamant that they were fine in their diet <– my favorite part).
3. A patient who had uncontrolled diabetes who told the nurse that he felt short of breath at home, so he took some cocaine. This same patient told me he does not take his blood sugar at home because he gave his machine to a friend…sure.
4. A patient (came in as an overdose) who threatened to pull out his IV if he didn’t receive pain meds (the nurse told him he could sign himself out AMA if he wanted, and he became very quiet).
5. Seeing x-rays with a collapsed lung, fluid in lungs, and blood clots.
6. A patient (next door to the patient I was visiting) who was screaming that the nurses were trying to kill him.

Some things I found to be useful during my rotation were:
1. A sheet with lab values and what it means to be high and low.
2. A sheet with common diseases (cirrhosis, diabetes, cardiac, renal failure, pancreatitis, etc) and the accompanying diets (for the ones I wasn’t familiar with).
3. A sheet with TF formulas used in the facility.
4. A cheat sheet of when to use certain formulas (Nepro-renal, Glucerna-Diabetes, Isosource-low blood pressure).
5. Knowing that I needed to be confident in my recommendations for a diet!
**Don’t stress too much over not knowing things about clinical. I felt the same way going into my rotation; however, by my last few weeks, I felt like I knew so much and how to appropriately apply the information.

I’m excited to start the next part of my RD Journey. T minus 5 weeks until graduation!


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Accomplishing a Week Full of Stressfulness

At this point in my inpatient clinical rotation, I am 5.5 weeks in with about 14 days left to go! Despite my 3 hour total commute every day, this rotation has been my favorite so far (something I thought I would never say!).

IPC is both challenging and rewarding at the same time. Seeing a really complicated patient and trying to figure out the best nutrition advice is like being a detective. You need all of the pieces (patient’s medical history, hospital care, food intake, etc) before you give tips on how to eat healthier. Missing something like Chronic Kidney Disease (need lower protein) or not knowing if a patient is on dialysis (higher protein is needed), can really alter what you say.

This week, I had some really dumb moments, like thinking LOS >7 meant a loss of 7 pounds (it really means length of stay > 7 days), really crazy moments (Seeing an anorexic patient who is receiving chocolate ensure via her tube feeding, since that is all she says she can tolerate; oh and she is receiving only 200-300kcal a day from her TF because she won’t let us increase her rate), really interesting moments (finding a patient who had a Whipple procedure done, which is now my new case study), really great moments (working with a quadriplegic patient to figure out calorie needs with high protein for wound healing), really sad moments (seeing a young patient go on hospice care from cancer), and really gross moments (taste testing boost pudding with prosource for a patient on a fluid restriction needing a supplement). Just as a side note, never ever try prosource unless you are dared to do so.

You never know what you will see when you are in a hospital. You will always see patients with CHF or diabetes (dia-be-tus as some call it in the hospital) or who are obese (some with a BMI of 51). What is frustrating is going to see a patient, who is diabetic and morbidly obese, and speaking to them about their diet. I can’t even count how many times a diabetic patient will say they are following a diet and don’t need any education, yet they gained weight from their last visit and/or are in for an amputation due to uncontrolled diabetes. It’s times like that where you need to be able to walk away and know that someone will not be able to change unless they really want to do it.

One of the best things for me, is following a patient from being in critical care in the ICU to the floors. It is especially awesome to see a patient come off a ventilator and be able to eat and function normally. I had a few patients over the past few weeks where I thought they would not be turning out okay. To my surprise, I am now following a lot of the patients out of the ICU and to their way home.

This week was really stressful in that I finished my research paper (10 pages on the effects of probiotics on antibiotic associated diarrhea, IBD, and IBS), presented my case study to my internship directors (my last one!), and worked on 2 additional case studies. It is often tough trying to manage my time properly between my internship (8.5 hours/day), 3 hour commute, part-time job where I teach nutrition, social life, and homework. One of the biggest tips I can give to anyone juggling a lot is to schedule in when you will do things. And by schedule, I mean put your assignments and plans on a calendar with a due date. One of my goals for this past weekend was to finish my research paper and find a new case study. I did both, even though I really wanted to just curl up and relax. Now, I have one less thing to stress about as I am finishing my rotation.

As I wrote my research paper, I came across some really great ways that helped me to figure out how to get 26 research studies into my paper in the right place. Here is what I found to be the best strategy for me:
1. Once you find a topic, gather all the information you will think you will need (plus more). I was trying to figure out what else to add to my paper after I got to 8.5 pages and couldn’t think of what else to write.
2. Either print the studies you find, or download as PDFs.
3. Go through each study and highlight important information you would use in your paper.
4. Create an outline of your paper: Paragraph 1: introduction, 2: probiotics, 3: C diff. 4: C diff and probiotics, etc
5. Type or cut and paste the information from each research paper into the word document with your outline under the appropriate sections.
6. When you start your paper, look back at all of the research pasted under each topic point in your outline.

I found this way easier to organize my thoughts. It may have been a little time consuming, but it definitely made the research paper much easier for me to tackle.

Finally, this is my last week before I start my staff relief portion!


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Week 3-4 of my Inpatient Clinical Rotation

I’m almost through my 4th week of my IPC rotation! Last week, I rotated with the RD in the ICU. This week, I rotated with the RD on the general patient floors. I’m not sure which one I like better at this point.

The ICU rounds are really intense! We (myself and the RD) rotate patient rooms with nurses, pharmacists, the intensivist, and a speech therapist. It is really interesting to talk so in depth about a patient. The intense part is when they start talking about medications, interactions, and using big medical jargon. I definitely take a lot of notes! The one thing about ICU, is you don’t get to interact with patients much. You look at a ton of labs and do ventilation calculations (calculating energy requirements for a patient on a ventilator, taking into account the medications they are on). You also write a lot of TF or TPN recommendations, but that’s about it.

When I rotate on the patient floors, I get to do a lot more educations (Coumadin, CHO-controlled diet, Renal diet, etc). You really get to chat with the patient about their home eating and the diet they are on. You might recommend/initiate a supplement and you track what the patient eats as well. Some patients are way more talkative and inviting than others. Also, don’t judge anyone by their age. I met a patient today, who was in her 90s, still living on her own and cooking all her meals. She was lively and in relatively good health. Later today, I went on a home care visit and met a lady in her early 60s. She was using a walker, had uncontrolled diabetes (BG levels in the 500-600s), and was achy and in pain. She was an “interesting” visit, to say the least. Some of my favorite quotes from her were, “I only buy pork chops to chew on the bone,” “Why do I even have to eat protein?” and my favorite, “I may eat some spar-a-grass tonight (aka asparagus).”

Some of my other favorite moments/quotes of the week were:
1. “My weight has been stable at home, but high. But that is because I eat a lot. I eat cake cookies, candy. I know I shouldn’t but I do anyway.” (Patient had: T2DM, CHF, Obesity, Renal failure etc)
2.  “Your name sounds like a nice soft kitty.” (From an 80 year old patient to me. What she meant, I don’t know).
3.  Patient: “You won’t believe me when I say why I am here. The KKK are after me and my neighborhood and I can’t believe it is not covered on the news yet.” (enough said).
4. Meeting a 3 year old patient in PEDs with a PEG tube in. He was so cute and sweet! He was born premature, but looked as normal as could be now.  He was my first PEDS patient thus far 🙂

So far,  I really like the rotation. It is very busy! I come in and do research on patients (medical/food and nutrition history, diet orders, etc). I calculate TF and calorie/protein/fluid requirements on a daily basis. I do all of the nutrition assessments when I rotate with the RD and I have been doing most of the patient educations. I feel like I am getting to know some things like the back of my hand. I really like the fast paced nature of the hospital. It is always different and there are always, always interesting patients to see 🙂


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First Week of my Inpatient Clinical Rotation

This week, I completed my first full week of my inpatient clinical rotation. I’ve found myself really liking being in the hospital. Each day is so different. One of the best things about being in clinical is there is always a variety of diseases, diets, and interesting medical histories.

Every day when I came in, I would research the new patients (needing initial assessments) and follow-ups for the day. I sifted through EMRs on the computer to find the patient’s height, weight, BMI, medications, allergies, I&Os, diet orders, and lab values. Using the information I researched, I would calculate the patient’s energy, protein, and fluid needs. When the RD came in, we would go out on the floor and do patient rounds. After the first few days, I was charting on all of the patients we saw (with supervision).

There were some really interesting patients this week. One lady had her stomach removed a few years ago and her intestine stretched to create a pouch. I ended up calculating her tube feeding recommendation. She was one of the many tube feeding recommendations I calculated this week (and 1 TPN). Another patient I saw, had a PEJ tube and a G-tube for drainage due to cancer. The patient ended up excreting almost 3 liters of fluid and was severely hypovolemic and had hyponatremia.

I also saw 2 swallowing evaluations this week. I was in the radiology room with the patient and technicians. They would give the patient a small amount of food (applesauce, cottage cheese, etc) with barium in it. They would then have a screen where you saw the food enter the patient’s mouth and esophagus. Both patients I saw had food get stuck in the esophagus, due to poor swallowing abilities. One patient ended up back on NPO and the other was advanced to pureed. Just as a side note, I had to taste test a pureed diet for an assignment. One item I tasted was pureed chicken. It tasted like gross chicken mashed potatoes. I would definitely not suggest trying that if you don’t have to.

One of the hardest things in clinical was seeing patients with a laundry list of diseases and medications. A lot of the issues were diet related. I saw a few patients with amputations due to uncontrolled diabetes and bedridden patients due to their morbid obesity. The craziest part was that they were still adamant on not changing their diet to a healthier one. It was rewarding to talk to a patient that was interested in what you had to say. One of the patients I got to educate had a cardiac diet. We talked about how he could lower his sodium intake at home and the importance of small changes to make a habit stick.

I really found it to be helpful to have a clipboard and small binder with equations (calculating protein, calories, ideal body weight, and fluid needs), lab values (and what they mean for disease states), and tube feeding information. You could also use an IPad if your facility allows you to. I also brought a small notebook on rounds with me so I could jot down information about the patient and tips for performing a nutrition assessment. It definitely gets easier the more you do it.

Next week, I will be with another RD that does the ICU rounds. I’m really excited to participate in interdisciplinary meetings on patients.