Where I'm At

I am in my third week at my job and am happy to let the world know I am finished training!  I will be on my own starting this Friday working with the postpartum, medical, and surgical patients.  I am a little nervous, but I feel pretty comfortable especially since normal training lasts another week or so but my supervising dietitian thinks I am already ready.  In the meantime, I have FOUR days off during a surprisingly spectacular sunny October week. 

Although I would love to put in 8 hour days at the beach, I really need to study for my DTR exam.  Especially because (drum roll please) the supervising dietitian wants me to start training with the current diet tech in the office in about a month!  There are currently two diet techs on staff (makes sense because there needs to be one on duty everyday) and one is retiring after working at this hospital for 26 years, wow!  She has incredibly big shoes to fill, but I can't think of someone better to train me!  In the meantime, I want to get my certification ASAP so I have it done and out of the way.  From what I can observe, the diet tech on duty receives the patient's meal requests that the hostesses put into the computer.  It is the diet tech's responsibility to make sure the meal is balanced and appropriate to the patient's diet order (i.e. a patient with a carb control diet cannot have fruit and juice for breakfast therefore the tech will alter it to fruit and a diet cranberry juice). 

There is so much to study for the DTR test!  Of course there is a broad spectrum of clinical topics ranging from carb counting to diverticular disease to renal diets.  There are also topics from the food service category including management, temperature control, and costing.  And don't forget food science! I'm also brushing up on maillard reactions, egg coagulation and syneresis, and the differences between soluble and insoluble fiber.  These are all things I can think of off the top of my head; there are just so many different questions that could pop up on this test!  Luckily, I have a study guide a previous student gave to one of my teachers from college that I have been using.   

[Sidebar, can I tell you how happy I am right now!?  I don't want to jinx said happiness, but so many things in my life are amazing and I am cautiously waiting for it all to crash down.  Moving away from the city and friends I loved to doggy paddle to keep my head above the waters of uncertainty, unemployment, and unhappiness left me with some dark days this summer.  Now I feel happy and that I have a purpose.  I am on a path and can see hazy images of my life as a Registered Dietitian.  In fact, my supervising dietitians are hoping I can stay on as a tech on weekends if I start a local DI next year.  They even went so far as to say that if I stayed and showed commitment, they could add me to their staff of RD's once I was certified.  WHAT?! It's very far down the line, but who wouldn't want to hear that?!

I've also been unexpectedly losing weight since I started working.  I was trying to get in better shape this summer to lose my beer/fireball/wine/tritip/baconwrappedhotdog belly from my last crazy quarter of college.  I ate healthier, worked out, and monitored everything on a great ap called My Fitness Pal.  However, I didn't really see any results.  All of a sudden I start working full time and am down 7+ lbs.  I don't completely understand why this happened.  Maybe it does take a couple of months to get noticeable results.  I do think it is helpful that I am on my feet, delivering trays, and pushing carts for 8 hours.   Another factor would be waking up earlier and going to bed earlier.  If I'm not up late, I'm less likely to get late night munchies.  My weight loss has nothing to do with the amazing free hospital food either; last week alone I ate ceviche, blackened salmon, and carne asada tacos!  So, I guess if you need to lose weight, start waking up before the sun and find a job where you're on your feet 40 hours a week :) ]

Patients Deserve Your Patience

I apologize for not posting in a while, but this new job is making me (happily) busy.  I'm feeling comfortable working in a hospital environment, talking to patients, and collaborating with other people that work at the hospital (charge nurses, RN's, dietitians, etc). I wanted to share some wisdom that was shared with me about working with "difficult" patients. If you ever held a job in customer service you are familiar with the following phrase: the customer is always right.  They may be called patients in a hospital, but they are also considered customers. They are paying the hospital for healthcare/treatment, which includes the proper nutrition found in their meals.

When doing menu selections with patients at our hospital, it can be more similar to a restaurant selection than typical hospital food. The patients are given as many options that fit into their diet plan as possible. Sometimes the occasional patient will become very particular or picky about what they ordered, similar to a customer one might serve at a restaurant. Sometimes the occasional patient is difficult. Sometimes the occasional patient will be angry at you for something you don't deserve. Sometimes the occasional patient is a perfect storm of picky, particular, difficult, and angry.  Still, the patient is not only always correct, but needs to be reassured and comforted. The number one goal for every patient is recovery and wellness.  To help put things in perspective, someone at work shared the following fantastic advice with me: a lot of patients in the hospital find themselves with nothing to control.  Their bodies might be failing them. Their doctor may have them on medication they don't understand. They may be under a doctor's orders they don't want to follow. However, they do control their food choice. Some patients may take their food orders more seriously than others because it is the only thing left that they can control.  This means when someone asks you for 5 Splenda packets or gravy on the side or a completely new order you apologize, take a deep breath, keep smiling, and admit you're wrong even if you know you're not.  You need to be able to leave the room knowing the patient is satisfied  with their meal choices and not angry at you or the menu.

Our goal as nutrition employees at the hospital is to encourage the intake of adequate foods to get patients on the road to recovery. So the patient is always right.  A happy patient will be happy to see their meal when it arrives.  Meal satisfaction leads to adequate energy intake.  Adequate energy intake helps recovery.  Recovery puts the patient back into optimal health.  The patient is always right.  Simple as that.

These are a Few of My Favorite Things

As you already know, I love cooking and baking.  I always like to try new recipes, but there are several old faithful crowd pleasers I know I can always count on.  I pinkie promise I will do some DTR studying today, but after a long 40 hour week I wanted to post something  for you foodies.  I added pictures to entice you and provided a link to each recipe.



Grilled Chicken Thighs with Ancho-Tequila Glaze
This a BBQ recipe from the magazine Cooking Light.  If you've never checked out the magazine, I highly suggest you do!  The recipes are on the lighter side, but always deliver on taste and the "yum" factor.  These are AMAZING.  Since I've moved back home, we've probably had them at least five times.  We usually skip the wood chips, use honey instead of agave, and regular chile powder instead of ancho; do what you want!  Promise me you will try these.  I can guarantee you will come back to them again and again.  

http://www.myrecipes.com/recipe/grilled-chicken-thighs-50400000122078/


Avalanche Bars
This recipe comes from the Rocky Mountain Chocolate Factory.  They are extremely quick and only require a microwave, in fact the first time I made these was during the Super Bowl halftime this year.  If you are a fan of Rice Krispie treats and think they are easy, wait until you make and eat these.  When you cut them you are left with lots of yummy avalanche crumbs-don't even think about tossing them!  They are a great snack for the deserving cook. 

http://www.thesweetslife.com/2012/07/avalanche-bars.html



Pioneer Woman Restaurant Salsa
I'm completely obsessed with Ree Drummond, the "Pioneer Woman."  She is an unintentional cowgirl who lives on her family's cattle ranch.  Her food is simple yet satisfying and scrumptious.  Knock on wood, but everything I have made from her has been FANTASTIC!  I have tried her stuffed shells (delicious), shortbread cookies (the PERFECT recipe), dreamy apple pie (can you say whiskey whipped cream?)and tortilla soup (great to make for the whole week).  I have been on the wait list for her cookbook at the library, which is finally ready for me today.  I guess Christmas came early this year!  Anyways, this salsa is incredible and very easy to make; you will never buy pre-made salsa again.  This ingredients are mostly canned, with some fresh items that bring it to life.  Throw everything in the Cuisinart and you'll have about 2 jars of homemade salsa!  I hate spicy foods but accidentally doubled the jalapenos and didn't have a problem with the result.  I use this salsa everyday by mixing it with egg beaters, then scrambling them.  ¡Muy delicioso!

http://thepioneerwoman.com/cooking/2010/01/restaurant-style-salsa/



Baked Monster Cookies
Baked is a fantastic bakery in Brooklyn that makes these cookies containing peanut butter, oatmeal, chocolate chips, and M&M's.  This makes a ton of cookies, but they are a total crowd pleaser!  Just make sure people with nut allergies are aware they contain peanut butter.  I also think everyone should have a copy of at least one of their cookbooks.  They have fantastic classic dessert recipes.

http://www.annesage.com/blog/2009/01/to-die-for-recipe-monster-cookies.html


Green Goddess Tabbouleh 
This recipe looks and tastes healthy.  It's chock full of fresh herbs and I like to make it with quinoa for added protein.  I used to make it in college to have as a quick lunch or dinner during the week.  You can make it on Sunday and it holds very nicely throughout the week. 

http://www.greenlemonade.com/recipes-juices/green-goddess-quinoa-tabbouleh/


Vegan Blueberry Pie Pancakes 

These come from a great website called Chocolate Covered Katie which has tons of creative and yummy healthy dessert recipes.  I happen to love these with orange zest and toasted chopped almonds on top, yum!  Best thing (for me) about this recipe, is it only makes a single serving so you're not stuck standing over a stove and left with 27 extra pancakes.  You could make a couple little pancakes, but I like to make one huge and satisfying vegan blueberry masterpiece!

http://chocolatecoveredkatie.com/2011/06/09/blueberry-pie-pancakes/

Made these while nannying over the summer

Soft Pretzels
These are 100% impressive and from Alton Brown.  The recipe is surprisingly easy and produces the most beautiful pretzels you have seen, not to mention the smell that will fill your kitchen is going to make you think you died and went to heaven.  They look like pretzels you find on carts or at baseball games because they come out golden brown.  However, these taste ten times better than those you can buy from a vendor.  You actually boil these for about 30 seconds in water and baking soda prior to oven baking, similar to how bagels are made.  Don't hold the mustard either, it's a must for these golden beauties!  If you want, the link has a video from Alton's show where you can watch how the pretzels are made.

http://www.foodnetwork.com/recipes/alton-brown/homemade-soft-pretzels-recipe/index.html

A batch I made three weeks ago

Cake Mix Doctor's Mom's Layer Cake with Fluffy Chocolate Frosting
This has been my go to birthday cake and cupcake recipe for 5 years.  It's that good.  Yellow cake with chocolate frosting is the ultimate birthday cake to me, and this recipe has never failed me.  It's just as simple as making a cake with a cake mix, except you use whole milk (no other kind of milk will do) and melted butter instead of oil and water.  You also beat the batter until it is nice and fluffy.  The chocolate frosting is exceptionally fudgey and will cause you to turn your nose at those of the canned variety after you try it.  After I frost these cupcakes, I like to dip them in a plate full of rainbow sprinkles.  These will make you feel five years old and bring you back to a time where you looked forward to turning another year older.  

http://familyfun.go.com/recipes/moms-layer-cake-with-fluffy-chocolate-frosting-679347/


Ina Garten's Potato Salad
I have never been a fan of potato salad.  Whenever I saw it I always thought of mass amounts of mayonnaise .  This recipe was a game changer for me; Ina's recipe is light and tastes fresh with all of the herbs utilized.  You can also sub in Greek yogurt for the mayonnaise (Greek yogurt is absolutely amazing and full of protein, please please try it if you haven't!  In general yogurt is a great sub for sour cream or mayo in savory recipes.) http://www.food.com/recipe/ina-gartens-old-fashioned-salad-365727

Overuse I Love You

I'm going to keep this one short and sweet.  Unfortunately there are some people who don't get to leave hospitals and end up spending their last days there.  I knew this coming into my job, but it wasn't until I was confronted with the situation yesterday that it really hit me.  A patient with a terminal illness was alive for breakfast, but not for lunch.  The shocking situation was so blatantly  front of me as I looked at the undelivered tray in my hands and it made me really sad.  The overwhelming  feeling of emotion caused me to doubt my ability to work in a hospital.  I know there are many other people who work in hospitals and have faced similar situations too many times to count.  It even made me think, "Is that ok?  To see death and keep working as if nothing happened?"  

I think what made me feel even worse was that I didn't remember who that patient was.  There are so many patients to see that it becomes easy to do what needs to be done and move on to what is next.  I'm not saying that I act like a robot when I see patients because that's accurate at all.  I try to be as warm and helpful as possible.  I doubt it was the case, but what if I was the last face that patient saw before they passed away? This made me reflect on bedside manner and the balance between getting things done efficiently while still being personable and friendly to patients.  Also about treating all units the same.  It's sometimes easier to be more friendly during comfortable situations.  Labor and delivery and postpartum are always my favorite units.  I enjoy visiting with the new mothers and watching them with their new babies.  Other departments with critically ill patients or those that are hard to understand usually make me want to get through their orders quickly.  It became clear to me that I need to act comfortably with all patients.  I realized that sometimes the patients that might make me uncomfortable deserve and just might need more personal attention.  The question that runs through my mind now before I enter any room, and especially those in critical care, is this: What if I am the last face this person sees?  I hope this is never the case, but you never know.

I came home yesterday and gave my dad a big hug.  I was reminded me to tell loved ones  that I love them and to show it often.  In the words of Lee Brice and one of my favorite songs, "Be a best friend, tell the truth, and overuse I love you.  Go to work, do your best, don't outsmart your common sense."

Brain Dump: Liquid Diets & Dysphagia Diets

I'm mostly doing this  to review for the DTR exam.  Feel free to skip this post or learn a little something about some clinical diet orders

Let's start with the liquid diets.  Liquid diets may be utilized for patients who are NPO (nothing by mouth).  A diet progression for this would go from Clear Liquid (CL) to Full Liquid (FL) to a soft diet (pureed foods) to a regular diet.

• Clear Liquids: broth, clear juices, jello, popsicles, coffee (no cream), tea.  You might not think of jello or popsicles as a liquid, but since both can be liquid if not chilled they are considered a clear liquid. This diet is usually short term since it isn't nutritionally adequate (not much protein or fat).  Reserved for situations such as post-op or bowel rest since it doesn't require much digestion or work from the GI tract (low residual)
• Full Liquids: cream soups, cream of wheat, custard, all juice, plain ice cream, pudding, butter, margarine, milk, yogurt.  These are all also liquid at room temp.  It is usually used as a transition from CL to a regular diet.  It contains more protein and energy than CL but still may not be able to provide enough overall energy.  Since most of the protein in this diet comes from dairy products, may be a problem for those with an intolerance.  

Since working, I do see a lot of CL's (posicles, Italian icees, jello, and broth which is always a soup option for lunch and dinner.  (There is low Na broth for cardiac diets).  As far as FL's, I see ice cream (sugar free and regular, both when appropriate), yogurt, milk, cream of wheat, vanilla pudding.  

Dysphagia diets are for those who have difficulty swallowing.  The primary complication with dysphagia is aspiration (which could affect the lungs and cause pneumonia) although weight loss and malnutrition may also occur because the patient is physically unable to intake regular foods or may not have an appetite for dysphagia appropriate foods.

There are 3 levels in the National Dysphagia diet (standard as of 2002)

• National Dysphagia Diet 1 (NDD-1) "Dysphagia Pureed" (I see this as Dys-1 on charts or heard verbally as pureed at work): food is pureed or pudding like, for example pureed meat or veggies, mashed potatoes with gravy (gravy helps make it moist and easier to eat, also adds flavor), applesauce.  NOT ok: jello(too thin), yogurt with fruit pieces (choking hazard), eggs, chunky cottage cheese, fried/hard-boiled eggs 
• National Dysphagia Diet 2 (NDD-2) "Dysphagia Mechanically Altered"  meats have been cut up using mechanical means such as a grinder/knife, vegetables may be steamed, soft or canned fruit, moistened cereals.  For example scrambled eggs, pancakes with syrup, banana, cereal flakes with milk, thickened beverages (ie OJ plus a thickener suck as Thicken up) NOT ok: bread, cake, rice, corn, peas, cheese cubes

ALSO: "Dysphagia Mixed" is a diet that uses NDD-1 plus one NDD-2 item (example menu: OJ, yogurt, cream of wheat, scrambled egg)

ALSO: "Mechanical Soft" is NDD-2 that allows bread, cake, and rice (example menu diced chicken+gravy, steamed rice, beets, pound cake, strawberries)

• National Dysphagia Diet 3 (NDD-3) "Dysphagia Advanced" for the most part, a regular diet, except patient must stay away from hard/sticky/crunchy items.  I like to call this the braces or retainer diet (remember back in the day of orthodontics when you had to stay away from caramel, gum, popcorm, corn nuts)  For example vegetable soup, shredded lettuce salad, sanwhich, melon, cookie (no nuts).  NOT ok: hard fruits and vegetables (apples, carrots), corn skins, nuts, seeds

Also good to know the progression of liquid terminology from thickets to thinnest: spoon thick, honey-like, nectar-like, thing liquids. (Thin liquid= water, ice, milk, milk shakes, coffee, tea, ice cream, jello; basically CL and FL)

This is not Grey's Anatomy. Let's talk about GERD while we're at it too!

Survived day two without dropping any trays, getting lost, or tripping over anything; winning.  Today I brought a notebook with me during menu selection rounds.  I got this tip from one of my favorite teachers who always had one with her when she did clinical hours during her internship.  I wrote down some things quite frantically and probably won't be able to distinguish it, but writing tends to help reinforce new things for me.  Although I didn't encounter any therapeutic dogs, I did get to see the babies again.  I even discovered a Starbucks in the hospital!  I had just assumed I was lost and had accidentally left the hospital, but to my surprise they have one on premises.  Babies and coffee, what more could I ask for?!    

I have to admit, sometimes I think I wound up in the world of Scrubs or Grey's Anatomy.  I'll see a janitor pass by and think he's going to sabotage me for his own amusement like the one on Scrubs.  Or I'll be eating in the cafeteria and expect to see McDreamy or McSteamy gazing at me.  That hasn't happened.  Yet.  No, working in a hospital is not as glamorous as they make it on TV.  Shenanigans do not occur in supply closets and actors/models do not double as surgeons.  Medical staff aren't there to entertain, they are there to help, serve, and treat patients.  Speaking of patients, I was deeply touched by one today.  We had seen this patient the day before and she knew I was on my first day of training.  Today she told me she was so happy to see me and asked how my first day had gone.  I replied that I was loving it.  The patient was incredibly happy for me and said they had prayed for me the day before that I would have a great first day.  I was blown away.  Here was this patient, sick and bedridden in a hospital bed, thinking of ME, someone healthy and walking around.  I know there will be more difficult patients in my future, but the fact that it is day two and I am already finding this job so personally rewarding puts the hugest smiled on my face.  

What I learned today:
1.  Hospitals typically do not carry pina colada flavored yogurt.
2.  There is a difference between a red and silver fire extinguisher.
3.  Thank God I remember my Spanish food vocabulary from high school.  Now if only I could casually pick up Vietnamese.
4.  When you ask one of the nurses in ICU how they are, said nurse responds, "The best I've ever had."  I just love nurses. 

Clinical Refreshers:
GERD (Gastroesophageal Reflux Disease): reflux of gastric contents into the esophagus 

• caused by things such as obesity, smoking, meds, and certain foods
• symptoms include dysphagia (difficulty swallowing), heartburn, increased salivation, belching, aspiration
• can be treated with medication such as antacids containing the 3 basic salts Mg, Ca, Al (Tums), foaming agents that coat the stomach to reduce symptoms (Gaviscon), H2 Antagonists to block histamine receptors which allow acids to be secreted (Pepsid AC), Proton Pump Inhibitors block enzymes that support HCl (acid) production (Prevacid), and prokinetics which speed up the stomach's ability to empty/decrease anything coming back up like nausea (Reglan*)
• Patients can also undergo surgery such as nissen fundoplication where the fundus is sutured to strengthen the lower esophageal sphincter (sphincter won't open as easily and allow acid to reflux)
• Nutrition therapy aims to do two things: avoid foods that relax the esophogeal sphincter (chocolate, peppermint/spearmint, fried foods, high fat foods, alcohol, decaf and regular coffee) or avoid foods that increase gastric acid secretion (dairy, alcohol, pepper, decaf and regular coffee).
• May also avoid these foods if they worsen symptoms: carbonated beverages, eggs, pastries, fried meats or fatty meats.  May also want to avoid large meals, laying down after meals, wearing tight clothing

On a completely unrelated note, these are the sturdy,
black, unattractive clogs I wear.  They're actually more
for nurses, but are suited for the kitchen while also
being comfortable for being on my feet all day.  I got
them at a medical supply store that sells scrubs.  They're in
my car because I don't want to bring any hospital
germs into my house.

*One time when I was in my medical drama phase, I wound up in the ER after I couldn't stop vomiting, which was causing me to immediately lose consciousness.  It had to do with a fluke recombination of low blood pressure and a flu bug.  According to my mom after I threw up, my pupils would roll into the back of my head, my eyes would stay open, and I would pass out.  Cute, right? Anyways, in the ER I was given Reglan to stop said vomiting and attractive eye ball rolling.  The nurse told my mom and I there was a 1% chance of an anxiety side effect, but it was extremely rare and we didn't have to worry about it.  Guess what, I am the 1%. (Jealous Eli Balaban?)  About 30 seconds after the Reglan was added to my IV, I got an intense and panicked feeling that I could not be in this ER and needed to go home.  I was focused on one thing, and that was getting out of bed and running home.  As I was about to rip my IV out, I was immediately sedated.  Good night.  I have a nutrition classmate who also had side affects with Reglan, however I'm pretty sure she was taking it at the time for GERD.  

Real World Day 1

Day one is done.  It. Was. A-M-A-Z-I-N-G.  I can't tell you how rewarding it is to put 4 years worth of knowledge in its arena.  Why yes, I know what NPO means.  You need to test the food for proper temperature?  Well, the danger zone is 41-140 F.  Coumadin?  No leafy greens for you!  There were also some things I was a little rusty on (like the dysphagia levels) but there's no better place to learn than in a hospital.  I'm totally getting completely lost in the hospital for the next couple of months by the way.  I wonder if the directions on my phone have a map for the building's maze, I mean layout.  

Anyways.  You know how I told you I wanted to be a baker when I grow up?  I still do, duh.  But maybe, just maybe, there is more in my professional future than  abusing butter and sugar.  That's right.  I want to become an RD when I grow up.  Except now I want to keep loving this position.  And get my DTR certification ASAP.  And probably bake 14 dozen cookies during the process. Plus the pb/chocolate cupcakes I need to make for Friday.

Shall I tell you about my day? Oh, alright.  Twist my arm.

6:30 AM Arrive.  Prepare trays of jello for the units we (the person training me+me) were responsible for.  Today we did Postpartum (labor and delivery, my favorite, I saw hours old babies, gahh), Oncology, ICU, and Telemetry (cardio).  We took these to the refrigerators in each department's kitchen station.  Made sure to move old foods to the front and dispose of anything with a date today and older.  

7ish Get trays from tray line and put on cart.  Push cart to unit.  Then we delivered the meals to each patient making sure we knocked on the door, told them who we were, gave them their food, checked to make sure the name on their bracelet or IV bag matched that on our order, and asked if there was anything else we could do for them.  Once a unit was finished, we would get a cart for another.  We don't deliver NPO meals or to those in isolation.  It was also important to be aware of signs on the door.  Some rooms required gowns and gloves if the patient had a certain illness.  

8ish-3 Take that day's lunch and dinner orders for patients who had just been admitted.  Then start taking breakfast/lunch/dinner orders for the next day.  This was done until 11:15 when lunch had to be delivered.  Then we worked on more orders until they were complete.  The orders are all put into a computer that has each patient's diet order information and sent to the diet tech.  Very cool.

What I learned:
-Patients in telly (telemetry) aren't allowed to have coffee or tea so it is not offered at all on that floor.  They also don't get ham.
-Nurses are amazing people.  No need to elaborate
-Kitchen staff are equally amazing and highly entertaining.
-This hospital has Vietnamese diet orders
-I forgot how many people are sick and in hospitals.  This is going to sound corny, but it totally made me appreciate my health.  My feet hurt because they weren't used to that much walking but it didn't seem that important after interacting with so many bedridden patients

Cool Things I saw
-Therapeutic dog.  This hospital has about 10-15 volunteers that bring their groomed and clean dogs to patients.  We met Andre who did about 7 tricks for an oncology patient we were taking an order from (high fives, shake, be ashamed, bow).  The patient loved it, he had 5 dogs at home and the 5 minutes spent with the dog put him at ease.
-Speaker Phone Translators.  Ok.  So imagine you are trying to take an order from a patient and they don't understand English.  Now, I know a good amount of Spanish.  However, this day there were Vietnamese and Farsi speaking patients.  Simply use a phone number to talk to an operator who puts a translator on the phone.  Phone is on speaker and translator talks as if they are in the room with you.  SO COOL.